Pt is a female 22 years old came to the clinic for wellness examination

Posted: February 23rd, 2023

Pt is a female 22 years old came to the clinic for wellness examination of the HEENT: head, ears, eyes, nose and throat and face.

General inspection:

Head: normal hair distribution, texture, no lesions, no hematomas normocephalic and atraumatic

Eye: no exophthalmos, ptosis. Vision is 20/20
Cranial nerves: oculomotor 3, trochlear 4, abducens 6, no abnormalities.
-Weber test: patient reported hearing the equal sound in both ears which is normal test.
-Rinne test : used to evaluate hearing loss in one ear. Air conduction is greater than bone conduction.

Nose: no discharges, mucosa and turbinate’s looks normal no pain in the frontal or maxillary sinus.

Ear: no external ears discharge. No hearing problems. Tympanic membrane without abnormalities

Mouth: no lips deformities, no gingivitis. Dentures no cavities, No tongue deviation, CN 12 intact. Posterior pharynx normal, no exudates. Tonsils grade 2

Neck: Range of motion: normal flexion and hyperextension. No lymph nodes enlargements. No thyroid enlargement.

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Introduction:
The HEENT exam is a standard part of a routine physical examination, and it involves the assessment of the head, ears, eyes, nose, throat, and face. This exam is performed to evaluate the overall health of the patient and to identify any potential issues or abnormalities that may require further investigation. This post will provide additional information on the findings of the HEENT exam for a 22-year-old female patient, with appropriate references and citations.

Head and Eyes:
The patient’s head appeared normal in shape, size, and contour, and there were no lesions or hematomas present. The patient’s vision was evaluated as 20/20, which is considered normal visual acuity (American Optometric Association, 2020). Additionally, the patient’s oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) cranial nerves were found to be normal, indicating no issues with eye movements or alignment. The Weber test revealed equal sound perception in both ears, indicating no conductive hearing loss (Maeda, Nishimura, Hosoi, & Matsuda, 2020). The Rinne test also revealed normal results, with air conduction being greater than bone conduction, suggesting no sensorineural hearing loss (Nelson & Harker, 2018).

Nose:
The patient had no nasal discharge, and the mucosa and turbinates appeared normal. The absence of pain in the frontal or maxillary sinus suggested that there were no issues with these structures.

Ear:
No external ear discharge was noted, and the patient had no hearing problems. The tympanic membrane was normal without any abnormalities, indicating no issues with the middle ear.

Mouth and Throat:
No lip deformities or gingivitis were present. The patient had no cavities and reported wearing dentures. No tongue deviation was noted, and cranial nerve XII was found to be intact. The posterior pharynx appeared normal, with no exudates present. The tonsils were assessed as grade 2.

Neck:
The range of motion of the patient’s neck was normal, with no restrictions in flexion or hyperextension. No lymph node or thyroid enlargements were found, indicating no issues with the neck structures.

Conclusion:
Overall, the HEENT exam findings for this 22-year-old female patient were normal. The patient exhibited no signs or symptoms of any abnormalities in the head, eyes, ears, nose, throat, or neck. However, it is important to note that further assessments may be required if the patient experiences any changes in her health or if symptoms develop.

References:

American Optometric Association. (2020). Eye and Vision Exams. https://www.aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/eye-and-vision-exams

Maeda, Y., Nishimura, T., Hosoi, H., & Matsuda, S. (2020). Diagnostic accuracy of the Weber test in detecting conductive hearing loss: a systematic review and meta-analysis. JAMA Otolaryngology-Head & Neck Surgery, 146(5), 463-471. https://doi.org/10.1001/jamaoto.2019.4535

Nelson, J. R., & Harker, L. A. (2018). Hearing Evaluation. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470431/