Correct
Partially correct
Incorrect
Missed
Head and Face Inspection:
0.67 out of 1 point
Skull Symmetry (1/3 point)
Balanced
Not balanced
Facial Feature Symmetry (1/3 point)
Balanced
Not balanced
Appearance (No point)
No noticeable strange findings
Skin rash
Small red bumps, pus-filled bumps, or blackheads
Skin growths (freckles, moles, or birthmarks)
Too much hair growth
Signs of skin injury (scar, cut, or bruise)
Red, dry nose
Eye and Orbital Area Examination:
1 out of 1 point
Orbital Area (1/4 point)
No noticeable strange findings
Drooping eyelid
Swollen eyelid
Skin lesion
Dark circles under the eyes due to allergies
Sclera (1/4 point)
White
Redness
Yellowish color
Conjunctiva (1/4 point)
Moist and pink
Pale
Dry appearance
Redness
Swelling
Conjunctival Discharge (1/4 point)
No discharge
Clear, watery discharge
Pus-like discharge
Nasal Cavity Inspection:
0.75 out of 1 point
Color (No point)
Pink
Pale
Red
Bluish
Discharge (1/4 point)
No discharge
Clear discharge
Bloody discharge
Pus-like discharge
Turbinate Patency (1/4 point)
Open
Partially blocked
Completely blocked
Observations (1/4 point)
No other visible strange findings
Foreign object present
Polyp
Hole in the nasal septum
Deviated septum
Skin lesion
Ear Examination:
1 out of 1 point
Right: Ear Canal Color (1/10 point)
Pink
Red
Pale
Right: Eardrum Color (1/10 point)
Normal grayish color
Red
Cloudy
Yellow
Not visible due to earwax
Right: Eardrum Appearance (1/10 point)
No unusual findings
Fluid seen
Scars visible
Bulging
Hole
Retraction
Right: Cone Of Light (1/10 point)
Position at 5 o’clock
Cone of light distorted
Right: Discharge (1/10 point)
No discharge
Earwax
Clear discharge
Bloody discharge
Pus-like discharge
Left: Ear Canal Color (1/10 point)
Pink
Red
Pale
Left: Eardrum Color (1/10 point)
Normal grayish color
Red
Cloudy
Yellow
Not visible due to earwax
Left: Eardrum Appearance (1/10 point)
No unusual findings
Fluid seen
Scars visible
Bulging
Hole
Retraction
Left: Cone Of Light (1/10 point)
Position at 7 o’clock
Cone of light distorted
Left: Discharge (1/10 point)
No discharge
Earwax
Clear discharge
Bloody discharge
Pus-like discharge
Mouth and Throat Examination:
1 out of 1 point
Oral Mucosa (1/6 point)
Moist and pink
Dry
Red
Tonsils (1/6 point)
No unusual findings
Swollen
Red
Tonsil Grade (1/6 point)
0: Normal size
1+: Tonsils cover less than 25% of the space between the tonsillar pillars
2+: Tonsils cover less than 50% of the space between the tonsillar pillars
3+: Tonsils cover less than 75% of the space between the tonsillar pillars
4+: Tonsils cover more than 75% of the space between the tonsillar pillars
Posterior Oropharynx Color (1/6 point)
Pink
Red
Posterior Oropharynx Texture (1/6 point)
No unusual findings
Cobblestone appearance
White patches
Post Nasal Drip (1/6 point)
No discharge
Clear discharge
Pus-like discharge
Neck Examination:
1 out of 1 point
Symmetry (1/2 point)
Symmetric
Asymmetric
Appearance (1/2 point)
No unusual findings
Swelling
Visible pulse
Visible lump
Change in skin color
Scalp Palpation:
1 out of 1 point
Tenderness (1/2 point)
No reported tenderness
Reported tenderness
Observations (1/2 point)
No other unusual findings
Areas of hair loss or thinning
Lumps felt
Sinus Palpation:
1 out of 1 point
Frontal (1/2 point)
No tenderness reported
Reported tenderness
Maxillary (1/2 point)
No tenderness reported
Reported tenderness
Temporal Artery Palpation:
1 out of 1 point
Right: Vibration (1/4 point)
No abnormal sensation
Abnormal vibration felt
Right: Intensity (1/4 point)
0 None
1+ Weak or barely felt
2+ Normal
3+ Strong
4+ Very strong
Left: Vibration (1/4 point)
No abnormal sensation
Abnormal vibration felt
Left: Intensity (1/4 point)
0 None
1+ Weak or barely felt
2+ Normal
3+ Strong
4+ Very strong
Carotid Artery Palpation:
1 out of 1 point
Right: Vibration (1/4 point)
No abnormal sensation
Abnormal vibration felt
Right: Intensity (1/4 point)
0 None
1+ Weak or barely felt
2+ Normal
3+ Strong
4+ Very strong
Left: Vibration (1/4 point)
No abnormal sensation
Abnormal vibration felt
Left: Intensity (1/4 point)
0 None
1+ Weak or barely felt
2+ Normal
3+ Strong
4+ Very strong
Jaw Palpation:
1 out of 1 point
Observations (1/1 point)
No abnormal findings felt
Limited movement
Clicking or popping sensation
Lymph Node Palpation:
1 out of 1 point
Head And Neck (1/3 point)
No enlarged nodes felt
Enlarged nodes felt on the right side
Enlarged nodes felt on the left side
Tina Jones HEENT Shadow Health Objective Data
Objective Data Collection: 24.42 of 25 (97.68%)
- Correct
- Partially correct
- Incorrect
- Missed
- Symmetric
- Asymmetric
- Symmetric
- Asymmetric
- No visible abnormal findings
- Rash
- Papules, pustules, or comedones
- Skin growths (freckles, moles, or birthmarks)
- Excessive hair growth
- Evidence of skin trauma (scar, laceration, or bruising)
- Red, chapped nose
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
- Allergic shiners
- White
- Injection
- Icterus
- Moist and pink
- Pale
- Dry appearance
- Erythema
- Edema
- No discharge
- Clear, watery discharge
- Purulent discharge
- Pink
- Pale
- Erythemic
- Bluish
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
- Patent
- Decreased patency
- Not patent
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
- Pink
- Red
- Pallor
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
- 5:00
- Cone of light distorted
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
- Pink
- Red
- Pallor
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
- 7:00
- Cone of light distorted
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
- Moist and pink
- Dry appearance
- Erythemic
- No visible abnormal findings
- Edema
- Erythema
- 0: Tonsils fit within tonsillar fossa
- 1+: Tonsils <25% of space between pillars
- 2+: Tonsils <50% of space between pillars
- 3+: Tonsils <75% of space between pillars
- 4+: Tonsils >75% of space between pillars
- Pink
- Erythemic
- No abnormal findings
- Cobblestoning
- Exudate
- No discharge
- Clear discharge
- Purulent discharge
- Symmetric
- Asymmetric
- No visible abnormal findings
- Swelling
- Visible pulsation
- Visible mass
- Discoloration
- None reported
- Tenderness reported
- No additional abnormal findings
- Balding or thinning areas in hair distribution
- Palpable masses
- None reported
- Tenderness reported
- None reported
- Tenderness reported
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No palpable abnormal findings
- Limited range of motion
- Popping or clicking
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable abnormal findings
- Nodules
- Enlarged
- Irregular
- None reported
- Tenderness reported
- Present in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- All areas clear
- Adventitious sounds in anterior right upper lobe
- Adventitious sounds in anterior right middle lobe
- Adventitious sounds in anterior right lower lobe
- Adventitious sounds in anterior left upper lobe
- Adventitious sounds in anterior left lower lobe
- Adventitious sounds in posterior right upper lobe
- Adventitious sounds in posterior right lower lobe
- Adventitious sounds in posterior left upper lobe
- Adventitious sounds in posterior left lower lobe
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No visible abnormal findings (PERRL)
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- No visible abnormal findings
- Nystagmus
- Fixed pupil
- No visible abnormal findings
- Unequal bilaterally
- Fixed pupil
- No abnormal findings
- Reduced right visual field
- Reduced left visual field
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
- Sharp
- Blurred
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
- Sharp
- Blurred
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
- Normal
- Conductive or sensorineural loss
- Normal
- Conductive loss
- Normal
- Conductive loss
- Normal
- Unable to hear whispered words
- Normal
- Unable to hear whispered words
- Intact
- Absent
- Hypersensitive
