Head, Eyes, Ears, Nose and Throat (HEENT)
HEAD atraumatic atraumatic, normocephalic (AT/NC) Battle's sign (cap the "B" - named for Dr. William H. Battle) facial pain facial weakness flattening of the (left/right) nasolabial fold fontanel (infant exam) headache macrocephaly/macrocephalic megacephaly/megacephalic microcephaly/microcephalic nasolabial fold normocephalic normocephalic, atraumatic (NC/AT)
EYES abnormal A-V ratio altered eye motion anicteric anisocoria arcus senilis arterial pulsation A-V crossing change Battle's sign best-corrected visual acuity black eye blood or hemorrhage in eye blurred vision cataract change in size, shape of pupils change in the color of the iris conjunctivae pink, not injected, clear, normal, muddy, no pallor cornea clear/cloudy corneal reflex intact crusty, swollen, inflamed eyelids darkness around or under the eyes decreased night vision disk/disc margins well-delineated disks/discs sharp double vision drusen dry eyes enucleated excessive tearing, watering exophthalmos extraocular movements (EOM) (may be dictated EE-OHM) extraocular movements intact (EOMI) (may be dictated EE-OH-MEE) focal constrictions foreign object in the eye fundi well-visualized/not well-visualized/not examined funduscopic examination, funduscopy H or E (hemorrhage or exudate) hard exudates homonymous hemianopsia increased cup to disc ratio iridectomy irregular pupil isocoria/isocoric (meaning the pupils are equal bilaterally) itchy or burning eyes lenticular opacification limbal injection lumps, bumps, sores on the lids macular degeneration medullated nerve fibers miosis mydriasis nonreactive/hyporeactive pupil nystagmus ocular swelling opacification opacified optic atrophy pain in or around the eye papilledema photophobia pigmentary disturbance preretinal and retinal hemorrhage protruding eyes ptosis (pronounced TOH-SIS) ptosis of eyelids Pupils (fixed/dilated/pinpoint) Pupils equal and reactive to light. (PERL) Pupils equal, round, and reactive to light and accommodation. (PERRLA) Pupils equal, round, and reactive to light. (PERRL) (above may be dictated as PURL or PURL-LAH) raccoon raccoon eyes rapid eye movements (REM) red eye red or pink eyes red reflex reduced vision retinopathy sclerae anicteric/icteric slit-lamp examination soft exudates strabismus strabismus/lazy eye swelling around the eyes visual acuity Eye Pathology Age Related Eye Conditions: Cataract, Glaucoma, Macular Degeneration, Presbyopia Congenital Defects: Congenital cataracts Degenerative Diseases: Retinitis pigmentosa Eyelid Disorders: Blepharitis, Chalazion, Ectropion, Entropion, Pinguecula, Pterygium, Ptosis, Sty/Hordeolum, Hypoxia/Hyperoxia, Retinal vessel occlusion Infection: Blepharitis, Conjunctivitis, Corneal ulcers and infections Eye Inflammation: Chemosis, Episcleritis, Hypertensive retinopathy, Optic neuritis, Scleritis, Uveitis Others: Amaurosis fugax, Amblyopia, Astigmatism, Blindness, Blocked tear duct, Coloboma of the iris, Colorblindness, Corneal injury, Dacryoadenitis, Eye floaters, Farsightedness, Gonococcal Ophthalmia, Keratoconjunctivitis sicca, Keratoconus, Melanoma of the eye, Nearsightedness, Optic atrophy, Optic Glioma, Retinitis Pigmentosa, Retinoblastoma, Retrolental Fibroplasia, Strabismus, Tay-Sachs disease
EARS auditory canal cerumen injected myringotomy tubes poor light reflex TMs (tympanic membranes) tympanic membranes intact - red/bulging/dull hearing loss equilibrium/balance problems dizziness/vertigo ear ache/pain fullness, tickling, itching in ear tinnitus/ringing in the ear lumps, bumps or sores in ear swimmers ear Ear Pathology Acoustic Trauma, Acute otitis media, Age-related hearing loss, Aural polyps, Barotitis, Benign ear cyst or tumor, Cholesteatoma, Chronic otitis media, Chronic Suppurative Otitis, Ear barotraumas, Ear discharges,bleeding, Ear foreign body, External otitis, Genetic Sensorineural Hearing Loss, Granulomatous Diseases, Infectious myringitis, Labyrinthitis, Labyrinthitis Ossificans, Mastoiditis, Meniere's disease, Middle Ear, Benign Tumors, Noise-Induced Hearing Loss, Occupational hearing loss, Otitis externa; acute, Otitis externa; chronic, Otitis media, Otitis Media with Effusion, Otosclerosis, Otosclerosis, Ototoxicity, Patulous Eustachian Tube, Perilymphatic Fistula, Pina abnormalities and low set ears, Presbycusis, Ramsay Hunt syndrome, Ruptured ear drum, Sensorineural deafness, Serous otitis, Sudden Hearing Loss, Syndromic Sensorineural Hearing Loss, Tympanic Membrane Perforations, Vascular obstruction, Wax blockage Diagnostic and Treatment Procedures Cochlear Implants, Fractionated Stereotactic, Implantable Hearing Devices, Middle Ear Endoscopy, Myringotomy, Ossiculoplasty, Radiation for Acoustic Neuroma External ear, aural atresia Related keywords: auricular atresia, congenital auricular deformity, small auricle, microtia, anotia, lop ear, cup ear, Stahl ear, peanut ear, anotic ear, peanut deformity, hypoplasia, hypoplastic ear, prominent ear, hemifacial microsomia, Goldenhar syndrome, Treacher Collins syndrome, Franceschetti syndrome, oculoauricular vertebral dysplasia, ear deformity, aural atresia, ear reconstruction Preauricular Cysts, Pits, and Fissures Related keywords: preauricular tags, epithelial mounds, pedunculated skin, preauricular sinus pit, sinus tracts, subcutaneous cysts, branchiootorenal syndrome, BOR syndrome, Beckwith-Wiedemann syndrome, mandibulofacial dysostosis, oculoauriculovertebral dysplasia, chromosome arm 11q duplication syndrome, chromosome arm 4p deletion syndrome, chromosome arm 5p deletion syndrome, preauricular cysts, pits, and fissures
NOSE bloody nose/epistaxis boggy turbinates boogers congested dry nose excessive sneezing flattening of the nasolabial fold inferior turbinate itchy nose loss of smell/anosmia nasal congestion/obstuction nasolabial fold polyps postnasal drip runny nose/excess nasal discharge septal deviation sinus turbinate/turbinate hypertrophy Nose Pathology Epistaxis / Nosebleeds, Foreign body nose, Nasal polyps, Nasal Polyps, Nose Fracture, Nosebleed – injury, obstructive sleep apnea, Rhinophyma, Seasonal Rhinitis, Sinusitis, Vasomotor rhinitis
THROAT and MOUTH aphthae aphthous ulcers bifid bifid uvula buccal mucosa cleft palate dentition difficulty swallowing/dysphagia drooling edentulous erythema exudate hard palate hoarseness/loss of voice mucous membranes moist/dry palate pharynx protruded tongue midline snoring soft palate sore throat temporomandibular joint thrush tongue well-papillated uvula and tongue midline uvula moves on phonation Pathology Breath odor, Canker sores, Chapped lips, Cleft lip and palate, Fever blister, Follicular tonsilitis, Geographic tongue, Gingivitis, Glossitis, Glossopharyngeal neuralgia, Herpes labialis, Leukoplakia, Macroglossia, Mouth ulcers, Oral cancer, Oral candidiasis (adult), Periodontitis, Perioral dermatitis, Pharyngitis, Posterior tongue carcinoma, Tongue tie, Tonsilitis Tonsillitis and Peritonsillar Abscess Related keywords: tonsillitis and peritonsillar abscess, quinsy, acute tonsillitis, recurrent tonsillitis, chronic tonsillitis, pharyngitis, pharyngotonsillitis, adenotonsillitis, PTA, inflammation of the pharyngeal tonsils, lingual tonsillitis, group A beta-hemolytic Streptococcus pyogenes, GABHS, GABHS pharyngitis, adenoidectomy, trismus, quinsy tonsillectomy, abscessed tonsil, bilateral tonsillectomy, sore throat, throat infection Adenoidectomy Related keywords: adenoidectomy, adenoid surgery, adenoid removal, infected adenoids, pediatric adenoidectomy, pediatric adenoid removal, pediatric adenoid surgery, tonsillectomy and adenoidectomy, T&A, adenoiditis, tonsillectomy, middle ear effusion, otitis media, OM, middle ear infection, rhinosinusitis, ear infection, ear disease, chronic sinusitis, COM, AOM, acute otitis media, chronic otitis media, otitis media with effusion, OME, adenoid curette, adenoid punch Velopharyngeal Insufficiency Related keywords: velopharyngeal insufficiency, VPI, velopharyngeal incompetency, velopharyngeal dysfunction, VPD, hypernasality, resonance disorders, cleft palate, palatoplasty, pharyngeal flap, pharyngoplasty, velocardiofacial syndrome, VCF syndrome, Kabuki syndrome, KS, Shprintzen syndrome
NECK EXAMINATION carotids 2+ and equal bilaterally, carotid bruit, cervical adenopathy, goiter, hepatojugular reflux (HJR), jugular venous distention (JVD), lymph nodes not palpable/palpable, hard, immobile, fixed, freely mobile, lymphadenopathy, multinodular goiter, pharynx, shotty lymph nodes [NOT shoddy], stridor, supple, thyroid not palpable, thyromegaly, venous distention at 45 degrees Pathology Lymphadenopathy/lymphadenitis Thyroid enlargement
HEENT DIAGNOSTICS 3-D X ray ASO Audiometry Auscultation CT scan Ear tubes are small plastic or metal tubes Eustachian Tube Placement Examination of mouth and throat Examination of nose and sinuses Fluorescein techniques Headache evaluation Inspection MRI Nasoscopic examination Neck examination (thyroid gland and lymph nodes) Ophthalmoscopic examination Otoscopic examination Palpation Perimetry Pulsatile irrigation Rapid strep test Retinoscopy Sinus CT Scan Slit lamp evaluation Standard tests of vision and hearing Temperomandibular (TMJ) pain Tonometry Tympanostomy Xoran Mini CT Scanner for sinus, ear, and TMJ visualization X-ray imaging
Treatment techniques Cervical lymphatic enhancement Ear "adjustment" (J) Ear acupoint stimulation Ear pump Eustachian tube opening decongestion technique Irrigation of the ear/ cerumen removal Lid flipping and foreign body removal techniques of the eye Sinus acupoint stimulation Sinus percussion/stimulation techniques Sinus pump Suboccipital stretch
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