Tina Jones HEENT Shadow Health Objective Data

HEENT Shadow Health Objective Data

Objective Data Collection: 24.42 of 25 (97.68%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Inspected head and face

0.67 of 1 point

Skull Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Facial Feature Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Appearance (No point)

•  No visible abnormal findings
•  Rash
•  Papules, pustules, or comedones
•  Skin growths (freckles, moles, or birthmarks)
•  Excessive hair growth
•  Evidence of skin trauma (scar, laceration, or bruising)
•  Red, chapped nose

 Inspected eyes and orbital area

1 of 1 point

Orbital Area (1/4 point)

•  No visible abnormal findings
•  Ptosis
•  Eyelid edema
•  Lesion
•  Allergic shiners

Sclera (1/4 point)

•  White
•  Injection
•  Icterus

Conjunctiva (1/4 point)

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema

Conjunctival Discharge (1/4 point)

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

 Inspected nasal cavities

0.75 of 1 point

Color (No point)

•  Pink
•  Pale
•  Erythemic
•  Bluish

Discharge (1/4 point)

•  No discharge
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

Turbinate Patency (1/4 point)

•  Patent
•  Decreased patency
•  Not patent

Observations (1/4 point)

•  No additional visible abnormal findings
•  Foreign body present
•  Polyp
•  Septum perforated
•  Septum deviated
•  Lesion

 Inspected ears

1 of 1 point

Right: Auditory Canal Color (1/10 point)

•  Pink
•  Red
•  Pallor

Right: Tympanic Membrane Color (1/10 point)

•  Pearly gray
•  Red
•  Opaque
•  Yellow
•  Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

Right: Cone Of Light (1/10 point)

•  5:00
•  Cone of light distorted

Right: Discharge (1/10 point)

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

Left: Auditory Canal Color (1/10 point)

•  Pink
•  Red
•  Pallor

Left: Tympanic Membrane Color (1/10 point)

•  Pearly gray
•  Red
•  Opaque
•  Yellow
•  Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

Left: Cone Of Light (1/10 point)

•  7:00
•  Cone of light distorted

Left: Discharge (1/10 point)

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

 Inspected mouth and throat

1 of 1 point

Oral Mucosa (1/6 point)

•  Moist and pink
•  Dry appearance
•  Erythemic

Tonsils (1/6 point)

•  No visible abnormal findings
•  Edema
•  Erythema

Tonsil Grade (1/6 point)

•  0: Tonsils fit within tonsillar fossa
•  1+: Tonsils <25% of space between pillars
•  2+: Tonsils <50% of space between pillars
•  3+: Tonsils <75% of space between pillars
•  4+: Tonsils >75% of space between pillars

Posterior Oropharynx Color (1/6 point)

•  Pink
•  Erythemic

Posterior Oropharynx Texture (1/6 point)

•  No abnormal findings
•  Cobblestoning
•  Exudate

Post Nasal Drip (1/6 point)

•  No discharge
•  Clear discharge
•  Purulent discharge

 Inspected neck

1 of 1 point

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

•  No visible abnormal findings
•  Swelling
•  Visible pulsation
•  Visible mass
•  Discoloration

 Palpated scalp

1 of 1 point

Tenderness (1/2 point)

•  None reported
•  Tenderness reported

Observations (1/2 point)

•  No additional abnormal findings
•  Balding or thinning areas in hair distribution
•  Palpable masses

 Palpated sinuses

1 of 1 point

Frontal (1/2 point)

•  None reported
•  Tenderness reported

Maxillary (1/2 point)

•  None reported
•  Tenderness reported

 Palpated temporal arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Intensity (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Intensity (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

 Palpated carotid arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Intensity (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Intensity (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

 Palpated jaw

1 of 1 point

Observations (1/1 point)

•  No palpable abnormal findings
•  Limited range of motion
•  Popping or clicking

 Palpated lymph nodes

1 of 1 point

Head And Neck (1/3 point)

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

Supraclavicular (1/3 point)

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

Axillary (1/3 point)

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

 Palpated thyroid gland

1 of 1 point

Observations (1/2 point)

•  No palpable abnormal findings
•  Nodules
•  Enlarged
•  Irregular

Tenderness (1/2 point)

•  None reported
•  Tenderness reported

 Auscultated breath sounds

1 of 1 point

Breath Sounds (1/3 point)

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

Adventitious Sounds (1/3 point)

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

Location (1/3 point)

•  All areas clear
•  Adventitious sounds in anterior right upper lobe
•  Adventitious sounds in anterior right middle lobe
•  Adventitious sounds in anterior right lower lobe
•  Adventitious sounds in anterior left upper lobe
•  Adventitious sounds in anterior left lower lobe
•  Adventitious sounds in posterior right upper lobe
•  Adventitious sounds in posterior right lower lobe
•  Adventitious sounds in posterior left upper lobe
•  Adventitious sounds in posterior left lower lobe

 Auscultated temporal arteries

1 of 1 point

Right (1/2 point)

•  No bruit
•  Bruit

Left (1/2 point)

•  No bruit
•  Bruit

 Auscultated carotid arteries

1 of 1 point

Right (1/2 point)

•  No bruit
•  Bruit

Left (1/2 point)

•  No bruit
•  Bruit

 Tested pupillary reaction

1 of 1 point

Observations With Penlight (1/1 point)

•  No visible abnormal findings (PERRL)
•  Unequal
•  Irregular
•  Miosis
•  Mydriasis
•  Non-reactive to light

 Tested extraocular eye movements

1 of 1 point

Cardinal Fields (1/2 point)

•  No visible abnormal findings
•  Nystagmus
•  Fixed pupil

Convergence (1/2 point)

•  No visible abnormal findings
•  Unequal bilaterally
•  Fixed pupil

 Tested peripheral vision

1 of 1 point

Observations (1/1 point)

•  No abnormal findings
•  Reduced right visual field
•  Reduced left visual field

 Examined fundus with ophthalmoscope

1 of 1 point

Right: Retina (1/4 point)

•  No visible abnormal findings
•  Myelinated nerve fibers
•  Papilledema
•  Glaucomatous cupping
•  Drusen bodies
•  Cotton wool bodies
•  Hemorrhage

Right: Disc Margin (1/4 point)

•  Sharp
•  Blurred

Left: Retina (1/4 point)

•  No visible abnormal findings
•  Myelinated nerve fibers
•  Papilledema
•  Glaucomatous cupping
•  Drusen bodies
•  Cotton wool bodies
•  Hemorrhage

Left: Disc Margin (1/4 point)

•  Sharp
•  Blurred

 Tested visual acuity

1 of 1 point

Right (1/2 point)

•  20/100
•  20/70
•  20/50
•  20/40
•  20/30
•  20/25
•  20/20
•  20/15
•  20/13
•  20/10

Left (1/2 point)

•  20/100
•  20/70
•  20/50
•  20/40
•  20/30
•  20/25
•  20/20
•  20/15
•  20/13
•  20/10

 Performed Weber test

1 of 1 point

Results (1/1 point)

•  Normal
•  Conductive or sensorineural loss

 Performed Rinne test

1 of 1 point

Right (1/2 point)

•  Normal
•  Conductive loss

Left (1/2 point)

•  Normal
•  Conductive loss

 Performed whisper test

1 of 1 point

Right (1/2 point)

•  Normal
•  Unable to hear whispered words

Left (1/2 point)

•  Normal
•  Unable to hear whispered words

 Tested gag reflex

1 of 1 point

Observations (1/1 point)

•  Intact
•  Absent
•  Hypersensitive