Inspect head and face - ANSWER -skull left tympanic membrane color: Pearly gray
symmetry: symmetric
left tympanic membrane appearance: No visible
facial feature symmetry: symmetric abnormal findings
appearance: Papules, pustules, or comedones left cone of light: 7:00
left discharge: No discharge
Inspect eyes and orbital area - ANSWER -
orbital area: No visible abnormal findings
Inspect mouth and throat - ANSWER -oral
sclera: White mucosa: Moist and pink
conjunctiva: Moist and pink throat color: Pink
conjunctival discharge: No discharge throat texture: No abnormal findings
tonsils: No visible abnormal findings
Inspect nasal cavities - ANSWER -color: post nasal drip: No discharge
Pink
discharge: No discharge
Inspect neck - ANSWER -symmetry:
turbinate patency: Patent Symmetric
observations: No additional visible abnormal appearance: Discoloration
findings
Palpated scalp - ANSWER -observations: o
Inspect ears - ANSWER -right auditory additional abnormal findings
canal color: Pink
tenderness: None reported
right tympanic membrane color: Pearly gray
right tympanic membrane appearance: No visible
abnormal findings Palapated sinuses - ANSWER -frontal:
None reported
right cone of light: 5:00
maxillary: None reported
right discharge: No discharge
left auditory canal color: Pink
Palpated carotid arteries - ANSWER -right
1/5
, Shadow Health - HEENT Tina Jones Questions and Answers
vibration: No thrill
convergence: No abnormal findings
right intensity: 2+ Expected
left vibration: No thrill
Tested peripheral vision - ANSWER -
left intensity: 2+ Expected observations: No abnormal findings
Palpated jaw - ANSWER -observations: No Examined fundus with ophthalmoscope -
palpable abnormal findings ANSWER -right retina: Cotton wool bodies
right disc margin: Sharp
Palpated lymph nodes - ANSWER -head left retina: No visible abnormal findings
and neck: No palpable nodes
left disc margin: Sharp
supraclavicular: No palpable nodes
axillary: No palpable nodes
Tested visual acuity - ANSWER -right:
20/40
Palpated thyroid gland - ANSWER - left: 20/20
observations: No palpable abnormal findings
tenderness: None reported
Performed whisper test - ANSWER -right:
Normal
Auscultated carotid arteries - ANSWER - left: Normal
right: No bruit
left: No bruit
Asked about head problems - ANSWER -
"Do you get headaches?
Tested pupillary reaction - ANSWER - "Do you currently have a headache?
observations with penlight: No visible abnormal
findings (PERRL) "Other than headaches, are you experiencing
head problems?"
Tested extraocular movement - ANSWER -
cardinal fields: No abnormal findings Asked about frequency of headaches -
2/5