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