Primary Clinical Skills: Respiratory/EENT

Documentation Examples of Chest/Pulmonary:

1. Symmetric, non tender to palpation, equal rib expansion
2. Thorax with kyphotic deformity. Increased AP diameter. Decreased rib expansion.
3. No hypertonicity or Chapman Points palpated.

Documentation Examples of Lungs:

1. CTA B
2. CTA bilat, resonant to percussion in all fields
3. Diminished breath sounds in bilateral bases.
4. Diffuse expiratory wheezing.
5. +Rhonchi and dullness to percussion, right base
6. Lungs resonant. No crackles, wheezes, rhonchi. Appropriate AP diameter.
7. Hyperresonant, distant lung sounds with scattered expiratory wheezes.

Documentation Examples of ENT:

• PERRL (pupils equal, round, reactive to light)
• Nares clear
• Posterior pharynx clear
• Tonsils enlarged, exudate present
• Uvula midline
• 2 mm ulceration left buccal mucosa
• Left ear canal with desquamation
• TMs pearly gray with good light reflex
• Right TM bulging and erythematous

Documentation Examples of Head and Neck:

• Normocephalic, atraumatic.
• Scalp without lesions.
• Hair dry and brittle.
• No thyromegaly or enlarged lymph nodes.
• No JVD.
• No carotid bruits.

Documentation Examples of HEENT:

1. Head: Normocephalic / atraumatic. Hair with average texture. Eyes: Visual acuity 20/20 bilaterally, with glasses. Sclera white, conjunctiva pink. Pupils equally round and reactive to light and accommodation, measuring 4 mm and constricting to 2mm. Disc margins are sharp, no hemorrhages, exudates, or AV narrowing noted. Ears: Good acuity to cotton rub. TMs with good cone of light. AC > BC. Nose: Mucosa pink, midline septum, no sinus tenderness. Throat: Oral mucosa moist and pink, good dentition, no exudates noted on pharynx.
2. Head: NC/AT. Balding in front. Eyes: Visual acuity 20/100 bilaterally, without correction. Sclera white, conjunctiva injected. Pupils equally round and reactive to light and accommodation, measuring 3 mm and constricting to 2mm. Disc margins are sharp, no hemorrhages, exudates, or AV nicking noted, AV ratio 2:4. Ears: Acuity diminished to cotton rub, intact to spoken voice. TMs clear. Nose: Mucosa erythematous and swollen, clear drainage, midline septum, maxillary sinus tenderness. Throat: Oral mucosa moist and pink, dental caries in upper molars, no exudates noted on pharynx, erythematous pharynx.

Documentation Examples of Neck:

1. Supple. Trachea and thyroid midline. No lymphadenopathy.
2. Supple. Trachea midline. Thyroid midline, lobes palpated but not enlarged.  Anterior cervical nodes tender, measuring 1cm x 1cm, mobile and rubbery. No other lymphadenopathy noted.