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A HEENT examination is a portion of a physical examination[1] that principally concerns the head, eyes, ears, nose, and throat.[2]

Steps

A neurological examination is usually considered separate from the HEENT evaluation, although there can be some overlap in some cases.

Sample write-up

Category Item Sample text
Head “NC/AT” or “Normocephalic, atraumatic
Eyes ophthalmoscope EOM intact, PERRLA, anicteric, no injection, fundus WNL (within normal limits), no papilledema
Ears otoscope TM intact, noninflamed”
Nose otoscope “No congestion
Throat otoscope Oropharynx WNL” or “no erythema or exudate
Mouth otoscope “Moist mucous membranes, no thrush, no vesicles, no lesions, good dentition
Neck “No LAD, thyroid WNL, neck supple” (JVD and bruit may be reported here or in CV)

References

  1. ^ Swaminatha V. Mahadevan; Gus. M. Garmel (5 July 2005). An introduction to clinical emergency medicine. Cambridge University Press. pp. 267–. ISBN 978-0-521-54259-3. Retrieved 6 March 2011.
  2. ^ Deutsch, Laurence M. (2001). Medical Records for Attorneys. ALI-ABA. p. 57. ISBN 9780831808174. Retrieved 18 January 2018.