HEENT Assessment Notes

Head

• Size:

  • Normocephalic: Normal head size.

  • Assess if the head size is small.

• Shape:

  • Assess if the head is perfectly round.

  • Check for any scars.

Facial Features

• Eyes.

• Mouth.

• General facial symmetry and appearance.

Temporal Area Palpation

• Palpate the temporal area where it lines up with cranial nerves.

• Palpate at the lower joint area.

• Normal Findings:

  • Nontender.

  • Symmetrical movement of the jaw.

  • Smooth range of motion.

  • No cracking or popping sensation (crepitus or crepitation).

  • No swelling, bruising, or edema.

• Abnormal Findings:

  • Tenderness: May indicate infection in the area or ear infection.

  • Crepitus/Crepitation: Crispy, crackling feeling.

    • May be a baseline finding in patients with a history of jaw injuries or surgeries.

    • Always warrants further questions and investigation.

Neck Assessment

• Inspection:

  • Look for any swelling or bulging.

  • Observe the patient's range of motion (e.g., grabbing something from their purse, turning their head).

  • Assess range of motion by instructing the patient to:

    • Turn their head with resistance.

    • Tilt their head back and forward.

    • Try to put their ear to their shoulder without raising their shoulder.

  • Abnormal Findings:

    • Clicking during range of motion.

    • Deviated trachea: May indicate a pneumothorax or collapsed lung or a tumor.

• Thyroid Gland:

  • Inspect for diffuse swelling (goiter).

  • Palpation:

    • Palpate from the back or front.

    • Have the patient swallow while deviating the trachea slightly.

    • Normal Findings:

      • Nonpalpable thyroid.

    • Abnormal Findings:

      • Enlarged thyroid.

  • Auscultation:

    • Auscultate only if the thyroid is enlarged.

    • Listen for a bruit (turbulent blood flow).

    • Bruit indicates pressure on blood vessels due to enlarged thyroid, potentially caused by hyperthyroidism or a tumor.

    • Turbulent blood flow occurs when blood is pushed through a smaller space due to the enlarged tissue.

Lymphatics

• Assess lymph nodes in the head and cervical area.

• Procedure:

  • Use fingertips with gentle circular motions.

  • Lymph nodes are easily obliterated with pressure, so use light pressure.

  • Assess bilaterally, comparing lymph nodes.

  • Do not assess the carotid artery bilaterally.

  • Identify and state which nodes are being assessed (e.g., preauricular).

• Normal Findings:

  • Nonpalpable.

  • If palpable:

    • Soft.

    • Discrete (almost can't feel it).

    • Nontender.

    • Movable.

• Abnormal Findings:

  • Enlarged lymph nodes: Assess the area they drain from to identify the source of the problem.

    • Example: Inflamed submental lymph node suggests sinus or dental issue.

Eyes

• Structures:

  • Canthus.

  • Lacrimal apparatus (tear duct).

  • Conjunctiva and sclera.

• Assessment:

  • Ask the person to look up.

  • Sclera should be white; conjunctiva should be pink.

  • Look for overall skin changes like pallor.

• Variations of Normal:

  • Dark-skinned patients may have macules (freckles) on the sclera.

• Anterior Eyeball Structures:

  • Cornea: Assess color, shape (flat, regular, round).

  • Iris: Variations in eye color are normal.

• Pupils:

  • Normal size: 3-5 millimeters.

  • Assess for equality.

  • Pupillary Light Reflex (PERLA):

    • Pupils Equal, Round, React to Light, and Accommodation.

    • Pupils should dilate when looking at far-off objects and constrict when focusing on something close.

  • Abnormal Findings:

    • Fixed pupil (doesn't dilate or constrict).

    • Unequal pupil size.

    • May indicate head injury.

• Visual Fields:

  • Confrontation test: Checks peripheral vision.

    • Mirror the patient, covering the same eye.

    • Wiggle finger and ask when they can see it.

  • Smooth Tracking:

    • Assess using only their eyes, without head movement.

    • Abnormal Findings:

      • Nystagmus (bumpy eye movement), except in extreme lateral positions.

• Snellen Chart:

  • Tests visual acuity.

  • 20/20 is perfect vision.

  • The first number (20) is the distance from the chart (20 feet for the big chart, 14 inches for the small chart).

  • As the second number gets bigger, vision gets worse.

  • Example: 20/40 means at 20 feet, the person can read what someone with normal vision can read at 40 feet.

• Corneal Light Reflex:

  • Shine a light at the person's eyes and note where the light reflects.

  • It should reflect in the same spot in each eye; use a clock face to describe the location (e.g., 05:00 in both eyes).

Ears

• External Ear Assessment:

  • Check for devices (hearing aids, glasses).

  • Document piercings, rashes, lesions, excoriations.

  • Assess for odors.

  • Assess for tenderness.

    • Manipulate the tragus and pinna; there should be no pain.

    • Palpate the mastoid process for tenderness.

• Otoscope Use:

  • Pull the pinna gently up and back.

  • Hold the otoscope handle upside down, towards the top of the head for a better view.

  • Be gentle.

• Internal Ear Assessment:

  • Canal:

    • Should not be red, swollen, or have discharge.

    • Check for foreign bodies.

  • Tympanic Membrane (Eardrum):

    • Should be shiny, translucent, and pearl gray.

    • Abnormal Findings:

      • Bulging: Indicates fluid behind the eardrum.

      • Scarring: May indicate recurrent ear infections as a child.

    • Cone of Light Reflex:

      • In the right ear, the cone of light should be at the 05:00 position.

      • In the left ear, the cone of light should be at the 07:00 position.

Hearing Acuity

• Assessment:

  • Normal spoken conversation: Note if they lean in or ask to repeat.

  • Whispered voice test.

  • If they fail the whispered voice test, perform tuning fork tests (Rinne and Weber).

  • Tuning fork tests assess for sensorineural or conductive hearing loss.

Nose

• Assessment:

  • Assess patency (airflow) of each nostril.

  • Check if the nasal septum is intact (no holes).

  • Palpate the sinuses (underneath the eyebrows and underneath the cheekbones) for tenderness.

  • Normally, sinuses are nontender.

  • Tenderness indicates a sinus infection.

• Abnormal Findings:

  • Deviated septum.

  • Holes in the septum (common in cocaine users).

Mouth

• Lips:

  • Check for color changes.

  • Abnormal Findings:

    • Cheilitis: Dry, cracked lips with fissuring.

    • Lesions: Herpes lesions or cold sores.

• Teeth and Gums:

  • Teeth should be intact.

  • Assess breath for odors (alcohol, sweetness).

  • Variations of Normal (Dark-Skinned Patients):

    • Bluish color to the lips.

    • Dark pigmented gingival line.

  • Gums:

    • Should be pink with a stippled (dotted) appearance.

• Tongue:

  • Check under the tongue and sides for lesions or breaks in the skin.

  • Taste buds increase in size towards the back of the tongue.

• Buccal Mucosa (Inside of Cheek):

  • Should be without lesions or breaks in the skin.

  • A line of skin where gums sit against teeth is normal.

  • Variations of Normal (Darker Skinned Patients):

    • Hyperpigmented patches.

    • Milky, bluish-white coating that disappears when stretched.

  • Abnormal Findings:

    • Thick white plaques (Candida/yeast infection).

• Palate:

  • Check for color changes (jaundice can be seen).

  • Check for intactness (cleft palates).

  • Torus palatinus: A hard ridge on the hard palate (variation of normal).

Tonsils

• Graded on a scale of 1+ to 4+.

  • 1+ to 2+ is generally considered normal (non-swollen, normal pink).

  • Two plus (2+) with bright red color, swelling, and discharge is abnormal (indicating infection).

  • If the patient has no tonsils, document 0+.