Tina Jones HEENT Shadow Health Objective Data Collection
24.42 of 25 (97.68%)
Inspected head and face:
– Skull Symmetry: Symmetric
– Facial Feature Symmetry: Symmetric
– Appearance: No visible abnormal findings
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Inspected eyes and orbital area:
– Orbital Area: No visible abnormal findings
– Sclera: White
– Conjunctiva: Moist and pink
– Conjunctival Discharge: No discharge
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Inspected nasal cavities:
– Color: Pink
– Discharge: No discharge
– Turbinate Patency: Patent
– Observations: No additional visible abnormal findings
Inspected ears:
– Right: Auditory Canal Color: Pink
– Right: Tympanic Membrane Color: Pearly gray
– Right: Tympanic Membrane Appearance: No visible abnormal findings
– Right: Cone Of Light: 5:00
– Right: Discharge: No discharge
– Left: Auditory Canal Color: Pink
– Left: Tympanic Membrane Color: Pearly gray
– Left: Tympanic Membrane Appearance: No visible abnormal findings
– Left: Cone Of Light: 7:00
– Left: Discharge: No discharge
Inspected mouth and throat:
– Oral Mucosa: Moist and pink
– Tonsils: No visible abnormal findings
– Tonsil Grade: 0: Tonsils fit within tonsillar fossa
– Posterior Oropharynx Color: Pink
– Posterior Oropharynx Texture: No abnormal findings
– Post Nasal Drip: No discharge
Inspected neck:
– Symmetry: Symmetric
– Appearance: No visible abnormal findings
Palpated scalp:
– Tenderness: None reported
– Observations: No additional abnormal findings
Palpated sinuses:
– Frontal: None reported
– Maxillary: None reported
Palpated temporal arteries:
– Right: Vibration: No thrill
– Right: Intensity: 0 Absent
– Left: Vibration: No thrill
– Left: Intensity: 0 Absent
Palpated carotid arteries:
– Right: Vibration: No thrill
– Right: Intensity: 0 Absent
– Left: Vibration: No thrill
– Left: Intensity: 0 Absent
Palpated jaw:
– Observations: No palpable abnormal findings
Palpated lymph nodes:
– Head And Neck: No palpable nodes
– Supraclavicular: No palpable nodes
– Axillary: No palpable nodes
Palpated thyroid gland:
– Observations: No palpable abnormal findings
– Tenderness: None reported
Auscultated breath sounds:
– Breath Sounds: Present in all areas
– Adventitious Sounds: No adventitious sounds
– Location: All areas clear
Auscultated temporal arteries:
– Right: No bruit
– Left: No bruit
Auscultated carotid arteries:
– Right: No bruit
– Left: No bruit
Tested pupillary reaction:
– Observations With Penlight: No visible abnormal findings (PERRL)
Tested extraocular eye movements:
– Cardinal Fields: No visible abnormal findings
– Convergence: No visible abnormal findings
Tested peripheral vision:
– Observations: No abnormal findings
Examined fundus with ophthalmoscope:
– Right: Retina: No visible abnormal findings
– Right: Disc Margin: Sharp
– Left: Retina: No visible abnormal findings
– Left: Disc Margin: Sharp
Tested visual acuity:
– Right: 20/20
– Left: 20/20
Performed Weber test:
– Results: Normal
Performed Rinne test:
– Right: Normal
– Left: Normal
Performed whisper test:
– Right: Normal
– Left: Normal
Tested gag reflex:
– Observations: Intact
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Tina Jones HEENT Shadow Health Objective Data Collection
: 24.42 of 25 (97.68%)
- Correct
- Partially correct
- Incorrect
- Missed
- Symmetric
- Asymmetric
- Symmetric
- Asymmetric
- 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
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
- Allergic shiners
- White
- Injection
- Icterus
- Moist and pink
- Pale
- Dry appearance
- Erythema
- Edema
- No discharge
- Clear, watery discharge
- Purulent discharge
- Pink
- Pale
- Erythemic
- Bluish
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
- Patent
- Decreased patency
- Not patent
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
- Pink
- Red
- Pallor
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
- 5:00
- Cone of light distorted
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
- Pink
- Red
- Pallor
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
- 7:00
- Cone of light distorted
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
- Moist and pink
- Dry appearance
- Erythemic
- No visible abnormal findings
- Edema
- Erythema
- 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
- Pink
- Erythemic
- No abnormal findings
- Cobblestoning
- Exudate
- No discharge
- Clear discharge
- Purulent discharge
- Symmetric
- Asymmetric
- No visible abnormal findings
- Swelling
- Visible pulsation
- Visible mass
- Discoloration
- None reported
- Tenderness reported
- No additional abnormal findings
- Balding or thinning areas in hair distribution
- Palpable masses
- None reported
- Tenderness reported
- None reported
- Tenderness reported
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No palpable abnormal findings
- Limited range of motion
- Popping or clicking
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable abnormal findings
- Nodules
- Enlarged
- Irregular
- None reported
- Tenderness reported
- Present in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- 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
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No visible abnormal findings (PERRL)
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- No visible abnormal findings
- Nystagmus
- Fixed pupil
- No visible abnormal findings
- Unequal bilaterally
- Fixed pupil
- No abnormal findings
- Reduced right visual field
- Reduced left visual field
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
- Sharp
- Blurred
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
- Sharp
- Blurred
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
- Normal
- Conductive or sensorineural loss
- Normal
- Conductive loss
- Normal
- Conductive loss
- Normal
- Unable to hear whispered words
- Normal
- Unable to hear whispered words
- Intact
- Absent
- Hypersensitive