HEENT Section Physical Examination Transcription Examples

HEENT: Eyes: No scleral icterus or xanthelasma. Mouth: No oral pallor or cyanosis.

HEENT: Head and Face: No facial plethora. No signs of trauma. Eyes: Pupils equal and reactive to light bilaterally. Oral cavity pink and moist. There is no oropharyngeal erythema, no exudate. Uvula is midline. There is no swelling, no retropharyngeal swelling.

HEENT: Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Conjunctivae are clear. Oropharynx is clear and pink with moist mucous membranes. Tympanic membranes have serous fluid behind both of them, but there is no thickening of the tympanic membrane on either side. She has no opacity. No redness.

HEENT: Eye exam: PERRLA. EOMI. ENT exam: TMs and canals are clear. Throat is minimally erythematous posteriorly. No exudate or trismus. He has no obvious dental abscess. He has no tenderness with percussion. He has numerous teeth, which have been pulled and several, which have dental fillings.

HEENT: Moist mucous membranes. TMs and canals are clear. Throat is without erythema. Tooth #17 is missing. Tooth #18 is severely decayed. There is a piece of gingiva starting to cover the posterior cusp. There is no abscess seen.

HEENT: Eye exam: PERRLA. EOMI. She does have a lateral nystagmus. ENT exam: Slight nasal tenderness. No other facial bony tenderness. No step-offs.

HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. No papilledema or hemorrhages are seen. Moist mucous membranes. Throat is without erythema. There is no trismus. TMs and canals are clear. There are no loose teeth. No facial tenderness. Nasal septum is midline.

HEENT: Eye exam: PERRLA. EOMI. ENT exam: No facial droop. Moist mucous membranes.

HEENT: Moist mucous membranes. TMs: Canals are clear. Anterior fontanelle open and flat. Throat is without erythema.

HEENT: Moist mucous membranes. TMs are occluded with cerumen bilaterally. When removed, the left TM is erythematous with loss of landmarks. Throat is erythematous posteriorly. No exudate or trismus.

HEENT: Nonicteric sclerae. PERRLA. EOMI. No sinus tenderness. Left TM has little loss of landmarks, a little red. Right TM is normal. No pain with movement of the pinna. EACs are normal. No mastoid erythema or swelling. No displacement of the pinna. There is positive anterior chain lymphadenopathy, more on the left than on the right. There is no stridor, no laryngeal crepitus. Oropharynx shows moist mucous membranes with reddened tonsillar pillars with a midline uvula and no tonsillar exudate. There is no stridor, no meningismus.

HEENT: Nonicteric sclerae. PERRLA. EOMI. There is no injection to the left sclera. There is no obvious photophobia in a well-lit room. Fluorescein staining and slit-lamp examination reveals no foreign body. There is no hyphema. Negative Seidel test. There are some scratches over the cornea of the eye, over the pupil and the iris. There is no entropion or ectropion. There is no tilting of any of the eyelashes. Lifting up the eyelids reveals no foreign body.

HEENT: Normocephalic, atraumatic. She is tender with percussion over tooth #15. There is decay present throughout the entire oral cavity. No abscess noted.

HEENT: The patient is noted to have active bleeding present in the left anterior Kiesselbach’s plexus, left side of his nasal septum. There are a few clots present. No right-sided bleeding or clots seen. Posterior pharynx is clear.

HEENT: Nonicteric sclerae. Pupils are equal, round and reactive to light and accommodation. Extraocular muscles are intact. There is a noted left subconjunctival hemorrhage. No hyphema. Bilateral TMs are clear and shows no signs of hemotympanum. There is no septal hematoma. There is a laceration noted on the top of the head on the right. There is one on the bridge of the nose. There is obvious deformity to the nose, which may be chronic. There is a laceration below the left eye and zygoma region without any underlying bony tenderness. There is no maxillary or mandibular instability.

HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. The left ear is clear with no erythema, bulging or retraction of the TM. The right ear has a moderate amount of cerumen in the canal. There is no purulent drainage or bleeding noted. No edema of the canal. The TM cannot be fully visualized, what can be seen appears intact with good light reflex and proper landmarks. There is no tenderness with palpation to the tragus or pinna or with percussion to the mastoid process. Oropharynx exhibits no tonsillar swelling, erythema or exudate. Teeth are in good repair.

HEENT: Normocephalic, atraumatic. Pupils are equal, round, reactive. No nasal discharge, no mid facial trauma. He does have soft tissue swelling and some obvious bruising over the left cheek overlying the zygomatic arch down across the mandible on the left-hand side. His midface is stable. His dentition all appears to be intact. He does have a filling in one of the left upper molars from a root canal that was done last week. There is no intraoral laceration or bleeding. His TMs show no hemotympanum, and his maxilla and mandible are stable to palpation.

HEENT: Pupils were anisocoric and it was unclear as to whether the patient was aware of this. Right pupil was 4 mm and minimally reactive. Left pupil was 3 mm and reactive to light. Oropharynx is moist without erythema or exudate. He had some crusted blood in the nares. No evidence of septal hematoma. He had a small 1 cm laceration on the right occiput, which was hemostatic.

HEENT: The patient has a small crusted area in the right lower lip area, just adjacent to the vermilion border. There is some surrounding edema and erythema. No evidence of any Ludwig’s angina. The floor of the mouth is soft.

HEENT: Normocephalic and atraumatic. PERRLA. EOMI. TMs are intact with good light reflex. The patient does have slight edema noted to the area of the left external nose. The turbinates are not erythematous or edematous. She does have a slight area of edema to her inferior left eyelid. Pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric and not injected. Posterior oropharynx is pink and moist without erythema or exudate. She does have a small lesion noted to the area just superior to her left upper lip. It is a small, round, firm lesion that is most likely a cyst. There is no erythema or edema to the area. There is no purulent drainage. The patient states that the area has been there for approximately 2 years.

HEENT: Normocephalic, atraumatic. PERRLA. EOMI. TMs intact with good light reflex. Posterior oropharynx is erythematous with exudate bilaterally on his tonsils. He does have kissing tonsils that are 4+. There is no asymmetry of the tonsils. The uvula is midline. Soft palate rises symmetrically.

HEENT: Normocephalic, atraumatic. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx is without erythema. Mucosa moist and pink. No sinus tenderness was noted. The patient does have multiple dental caries with partial tooth avulsion and has some slight swelling of his gingiva of the right lower molar area, but there is no fluctuance or abscess palpated. No facial swelling was noted.

HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. Ears are clear with no hemotympanum. There is no septal hematoma. No nasal displacement. She does have a superficial 1.5 cm abrasion noted to the bridge of the nose with minimal tenderness to palpation to the bone here. There is no ecchymosis or swelling. No Battle or Raccoon sign. The remaining facial bones are otherwise unremarkable. Mucous membranes are pink and moist.

HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. Ears are clear with no erythema, bulging, retraction of the TMs bilaterally. Oropharynx exhibits no tonsillar swelling, erythema or exudate. There is no tenderness with percussion to the frontal or maxillary sinuses. Facies are symmetrical with no obvious swelling. He has very poor dentition. The molars of the left lower jaw are significantly decayed; however, there is no induration or fluctuance appreciated, very minimal erythema and a significant tenderness to percussion to the teeth. His upper and lower incisors have been extracted. There is no submandibular, sublingual or submental tenderness or swelling. No evidence of abscess. Buccal mucosa is normal.

HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. The patient does have a fleck of a foreign body noted on the cornea of the left eye in the 6 o’clock position, just at the pupil rim. There is minimal conjunctival injection. No lid edema or nodules appreciated. No purulent drainage. No photophobia noted. Mucous membranes are pink and moist. Oropharynx exhibits no tonsillar swelling, erythema or exudate. Ears are clear with no erythema, bulging, retraction of the TMs bilaterally.

HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. The left eye conjunctiva is slightly injected. No evidence of foreign body with gross examination or lid eversion. There is no purulent drainage noted. No lid edema or nodules appreciated. No tenderness to palpation. No photophobia. Under Woods lamp examination and fluorescein stain, there is a very small pinpoint abrasion noted in the 8 o’clock position overlying the medial iris. There is no streaming of fluorescein noted under slit-lamp examination. No evidence of puncture or global rupture. No cells or flare in the anterior chamber. Mucous membranes are pink and moist.

HEENT: The patient does have some facial swelling noted to the right cheek. There is no nasolabial fold swelling noted. No lip swelling noted. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted. The patient does have obvious dental caries noted to tooth #12. He does have some slight erythema and edema noted to the gums surrounding this tooth as well. No fluctuance palpated. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted.

HEENT: The patient has positive edema noted to the lower lip and anterior tongue consistent with angioedema. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx is without erythema or exudate. Mucosa is moist and pink. No sinus tenderness noted. The patient does appear to have some facial swelling noted to the right cheek as well. She also has small cold sores noted in the mucosa of the right lower lip.

HEENT: Head is normocephalic, atraumatic. Pupils are equal round and reactive to light and accommodation. Extraocular movements are intact. The patient has no pain with movement of extraocular muscles. She has no proptosis. The patient has no pain or tenderness around her orbits. She has no swelling around her eyes and no erythema around her eyes. Her face is symmetric. Her oropharynx is clear, and her uvula is midline.

HEENT: He had just some clear rhinorrhea noted. TMs are clear. Oropharynx shows moist mucosa.

HEENT: Nonicteric sclerae. PERRLA. EOMI. There is no septal hematoma, no sublingual hematoma, no malocclusion or malalignment of the teeth. There is slight ecchymotic area underneath the superior lip with a little tear of the frenulum that connects to the buccal and gingival mucosa. There are no loose teeth; although, there is some tenderness on moving, particularly numbers 8, 9 and 7. There is no bony tenderness to the face. No hemotympanum.

HEENT: He has dysconjugate eye gaze, divergent on the left side to lateral gaze. He has asymmetric pupils of 3 mm on the right and 4 on the left. These are minimally responsive to light. He is unable to cooperate with any further aspects of the neurologic examination and does not respond to lid opening.

HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes are moist without lesions.

HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes do show some vomit around the mouth but no lesions appreciated. There are no contusions, abrasions or lacerations about the head or face.

HEENT: The patient has 4 mm to 2 mm bilateral reactive pupils. The right eye is surrounded by a large amount of periorbital swelling and is swollen shut; however, we are able to open without difficulty, and the patient’s extraocular movements are intact underneath and also in the left eye. After everting the lids, there are no foreign bodies present; however, on fluorescein exam, it is noted that there are multiple corneal abrasions bilaterally in the eyes. However, there is a negative Seidel sign, and there does not seem to be any globe injury or globe penetration.

HEENT: Head and scalp are essentially atraumatic. Pupils are equal, round, reactive to light. Extraocular muscle movement is normal. Ears are without hemotympanum. Nose: No gross deformity. No obvious soft tissue swelling. There is no septal hematoma. No blood in the nares. Mouth: Moist membranes. Tongue is normal, although there is a piercing. Dentition is intact and there is no gross instability of either the face or teeth. There is a laceration, which extends through the vermilion border of the upper lip on the left side. This is approximately 1 cm long, and it appears to involve the oral mucosa as well. The lower lip has a laceration with some soft tissue swelling that is about 1 cm long as well; although, this does not cross the vermilion border. I do not appreciate any chipping of his teeth. Right jaw has one point of tenderness. There is no soft tissue swelling. He opens and closes the mandible normally and is able to fully open his mouth. There is no soft tissue swelling of the face.

HEENT: Head is normocephalic and atraumatic. Midface is stable. Extraocular movements are intact. Pupils are 4-2, sluggish bilateral. Mucous membranes are dry. Oropharynx is clear.

HEENT: Pupils are equal and reactive. Conjunctivae are clear. Scalp with some mild erythema noted over the occipital region. No hematoma. Subjective tenderness diffusely to palpation of occipital region. Bilateral tympanic membranes normal. No obvious facial trauma, teeth stable, no malocclusion. She has a decayed left lower molar, which is fractured at the crown. According to the patient, this fracture occurred when she was punched. She had no external facial swelling however.

HEENT: Pupils are equal and reactive. Conjunctivae are clear. Extraocular movements are intact. Tympanic membranes are normal. She had some mild tenderness to palpation over the right posterior auricular node and occipital node. She has some questionable folliculitis along the right occipital scapular area with some tenderness. No drainage.

HEENT: The patient has a 3.5 cm linear laceration just inferior to the hair of the right eyebrow. There is also 3 smaller abrasions noted lateral to that. His pupils are 2-3 mm equal, round and reactive. His head shows no other signs of trauma. His TMs are clear. No hemotympanum.

HEENT: No sinus tenderness. Bilateral TMs are clear. No pain with movement of the pinna. EACs are normal. Pupils are equal, round and reactive to light. Extraocular muscles are intact. There is no facial swelling. No palpable lymphadenopathy. No stridor. Intraoral examination reveals moist mucous membranes. There is fractured first tooth with obvious dental tenderness. No surrounding gingival erythema or fluctuance.