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Course 4: PE
Terms needed from course four for medical scribing.
| Question | Answer |
|---|---|
| When will a physician use only an external exam? | A physician will use an external exam when there is a minor complaint that will not need further examination. |
| What is considered normal in the General system external? | Well developed, well nourished, no acute distress. |
| What is considered normal in the Eyes system external? | PERRL |
| What is considered normal in the ENT system external? | Most Mucosa. |
| What is considered normal in the Neck system external? | Supple. |
| What is considered normal in the Cardiovascular system external? | Well perfused. |
| What is considered normal in the Respiratory system external? | No respiratory distress. |
| What is considered normal in the Gastrointestinal system external? | Non-distended. |
| What is considered normal in the Extremities system external? | No edema. |
| What is considered normal in the Skin system external? | Dry, no rashes. |
| What is considered normal in the Neurological system external? | Alert and Oriented. Normal speech. |
| What is considered normal in the Psychiatric system external? | Normal affect. |
| How many elements does a complete PE require? | 8 elements. |
| What is considered normal for a complete Constitutional system? | Well developed, well nourished. No acute distress. |
| What is considered normal for a complete Eyes system? | PERRL, EOMI. |
| What is considered normal for a complete ENT system? | Moist mucous membranes. |
| What is considered normal for a complete Neck system? | Supple, No lymphadenopathy. |
| What is considered normal for a complete Cardiovascular system? | Well perfused. Regular rate and rhythm. No murmurs, rubs, or gallops. Distal pulses intact. |
| What is considered normal for a complete Respiratory system? | No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. |
| What is considered normal for a complete Abdominal system? | Non-distended. Soft. Non-tender. No guarding, rebound, or rigidity. |
| What is considered normal for a complete Extremities system? | No edema, Full ROM. |
| What is considered normal for a complete Skin system? | Dry, No rashes, Warm. |
| What is considered normal for a complete Neurological system? | Alert and Oriented. Normal Speech. |
| What is considered normal for a complete Psychiatric system? | Normal affect. |
| What should be documented if the doctor examines the throat? | They are looking for Pharyngeal erythema or exudates. |
| What should be documented if the doctor examines the inner-ear? | They are looking for TM (ear-drum) erythema or bulging. |
| What should be documented if the doctor auscultates the abdomen? | They are looking for Hyperactive/ Hypoactive bowel sounds. |
| What should be documented if the doctor touches the wrists? | They are looking for radial pulses. |
| What should be documented if the doctor squeezes the calf muscles? | They are looking for calf tenderness. |
| What should be documented if the doctor "pounds" on the back? | They are looking for CVA tenderness. |
| If No Acute Distress (NAD), in General system is normal then what is abnormal? | Mild/Moderate/Severe Distress (due to pain). |
| If well developed and well nourished, in the General system is normal then what is abnormal? | Cachectic/ Emaciated/ Malnourished. |
| If Alert, in the General system is normal then what is abnormal? | Somnolent, Obtunded, Unresponsive. |
| If Atraumatic/ Normocephalic (AT/NC), in the Head system what is then considered abnormal? | Any signs of trauma, sinus tenderness, and angioedema. |
| If PERRL, is normal in the Eyes, what is considered abnormal? | Anisocoria (unequal pupils) |
| If EOMI, is normal in the Eyes, what is considered abnormal? | EOM entrapment. |
| If Sclera are anicteric, is normal in the Eyes, what is considered abnormal? | Scleral icterus (Liver Failure). |
| If Normal conjunctiva, is normal in the Eyes, what is considered abnormal? | Pale conjunctiva (Anemia), Conjunctival injection (Conjunctivitis). |
| Retinal detachment. | When the retina is separated from its supporting tissues. |
| Papilledema. | Is the swelling of the optic disc caused by intracranial pressure due to any cause. |
| Hyphema. | A collection of blood in the space between the cornea and the iris. |
| How is a corneal abrasion examined? | It is examined with fluorescein uptake and with a woods lamp. |
| What are some abnormal signs in the Tympanic Membranes (TM's) | TM erythema, TM bulging, TM dullness, and TM obscured by cerumen (earwax). |
| Epistaxis. | Nose bleed. |
| Rhinorrhea. | The nasal cavity is filled with a significant amount of mucus fluid. |
| Septal Hematoma. | When blood collects in the area of your nose between your nostrils, called the septum. |
| Boggy turbinates. | Swollen inner nose. |
| Nasal deformity. | Any abnormal variation of the appearance of a normal nose. |
| What is considered abnormal for the nose system? | Epistaxis, Rhinorrhea, Septal hematoma, boggy tubinates, and a nasal deformity. |
| What is considered abnormal for the mouth/throat system? | Dry Mucous Membranes (DMM), Dental Caries, Edentulous, Pharyngeal Erythema, Tonsillar Exudate, Tonsillar Hypertrophy, and Peritonsillar Abscess (PTA). |
| Carotid Bruit. | A vascular murmur sound heard over the carotid artery. |
| Cervical lymphadenopathy | Swollen lymph nodes. |
| What is considered abnormal in the neck and cervical spine system? | Jugular Venous Distension (JVD), Carotid Bruit, Cervical lymphadenopathy, Vertebral Point vs Paraspinal Tenderness, and Thyromegaly. |
| Tachycardia. | Counts as greater than 100 bpm. |
| Bradycardia. | Counts as less than 60 bpm. |
| What are some abnormal findings of the Cardiovascular (CV) system? | Tachycardia, Bradycardia, Irregularly irregular rhythm, murmur, extrasystoles, Pleural rub, and Gallop. |
| What is the contradiction of a regular rate? | Tachycardia or Bradycardia. |
| What is the contradiction of a regular rhythm? | Irregularly Irregular |
| What is the contradiction of a normal sounding heart? | Murmurs, Rubs, Gallops, Extra Systoles. |
| What is a 0 pulse? | Absent |
| What is a 1+ pulse? | Barely palpable. |
| What is a 2+ pulse? | Easily palpable. (Normal). |
| What is a 3+ pulse? | Full |
| What is a 4+ pulse? | Bounding/ Aneurysmal |
| What is the normal response for the Pulmonary system? | No respiratory distress, Clear to auscultations bilaterally. |
| What are some abnormal findings for the Pulmonary system? | Mild/Moderate/Severe Respiratory Distress, Tachypnea, Accessory Muscle Use, Diminished breath sounds, Wheezes, Rales, and Rhonchi. |
| What are the contradictions for no respiratory distress? | Mild/Moderate/Severe Respiratory Distress, Tachypnea, and Accessory muscle use. |
| What are the contradictions to Clear to auscultations bilaterally? | Diminished breath sounds, Wheezes, Rales (crackles), Rhonchi |
| What are the contradictions for soft and non-tender in the Abdominal system? | Mild/Mod/Severe Tenderness to Palpation (TTP), Voluntary Guarding, Rebound Tenderness, and Rigidity (Involuntary Guarding) |
| What is a pediatric abnormality in the General system? | Lethargic, Inconsolable, Febrile. |
| What is a pediatric abnormality in the Head system? | Sunken Fontanel, Bulging Fontanel. |
| What is a pediatric abnormality in the Eyes system? | Scleral Icterus |
| What is a pediatric abnormality in the Ears system? | TM erythema, Bulging. |
| What is a pediatric abnormality in the Throat system? | Pharyngeal erythema |
| What is a pediatric abnormality in the Neck system? | Lymphadenopathy |
| What is a pediatric abnormality in the Cardiac system? | Murmur, Tachycardia |
| What is a pediatric abnormality in the Respiratory system? | Wheezes, Stridor, Retractions, Nasal flaring |
| What is a pediatric abnormality in the Abdominal system? | Crying with abdominal palpations |
| What is a pediatric abnormality in the Genital system? | Erythema |
| What is a pediatric abnormality in the Extremities system? | Ecchymosis in various stages of healing |
| What is a pediatric abnormality in the Skin system? | Rash (diaper rash or eczema) |
| What is a pediatric abnormality in the Neurological system? | Postictal, Somnolent |
| What is the normal pediatric finding for the General system? | Non-toxic, Alert, Interactive, Playful, Crying with tears on exam, Quickly consolable |
| What is the normal pediatric finding for the Head system? | Flat Fontanel (if less than 8 months old) |
| What is the normal pediatric finding for the Eyes system? | PERRL, No Scleral Icterus |
| What is the normal pediatric finding for the Ears system? | Nml TMs |
| What is the normal pediatric finding for the Throat system? | Most mucous membranes |
| What is the normal pediatric finding for the Neck system? | Supple, no meningismus |
| What is the normal pediatric finding for the Cardiac system? | Regular rate and rhythm |
| What is the normal pediatric finding for the Respiratory system? | No distress, Clear and Equal |
| What is the normal pediatric finding for the Abdominal system? | Soft, No crying or grimacing with palpation |
| What is the normal pediatric finding for the Genital system? | Nml external, Testicles descended |
| What is the normal pediatric finding for the Extremities system? | FROM |
| What is the normal pediatric finding for the Skin system? | Warm, Dry, No rash |
| What is the normal pediatric finding for the Neurological system? | Alert, Appropriate for age, Moves all four extremities (MAEx4) |
| What is the General finding in a Code Exam? | Unresponsive |
| What is the Head finding in a Code Exam? | Normocephalic, Atraumatic |
| What is the Eyes finding in a Code Exam? | Fixed and Dialated |
| What is the Oropharynx finding in a Code Exam? | Airway patent, ETT in place |
| What is the Cardiovascular finding in a Code Exam? | Absent heart sounds, No palpable pulses |
| What is the Respiratory finding in a Code Exam? | No spontaneous respirations, Equal with controlled ventilation |
| What is the Abdominal finding in a Code Exam? | Distended |
| What is the Musculoskeletal finding in a Code Exam? | No deformities |
| What is the Skin finding in a Code Exam? | Pallor, Cyanotic, Mottled |
| What is the Neurological finding in a Code Exam? | Unresponsive, Neurological exam limited due to clinical condition. |
| Benign. | Normal. |
| Anatomical Position. | A frame of reference used to describe anatomy and movement. |
| Tenderness. | Pain felt on the release of pressure. |
| Atraumatic. | Without trauma. |
| Icterus. | Yellowing, also known as jaundice. |
| Purulent. | Pus-like. |
| Erythema | Redness. |
| Organomegaly. | Organ enlargement. |
| Perfusion. | The flow of blood through the body's blood vessels. |
| Affect. | Feeling and Emotion. |
| Consolable. | Able to be comforted. |
| GCS | Glasgow Coma Exam, used to assess level of consciousness in trauma patients. |
| What are the major DDX of headache? | Hemorrhagic/ ischemic CVA, Subarachnoid hemorrhage, brain CA, Meningitis, sinusitis, Temporal arthritis. |
| What are the findings for General system for headache? | No acute distress, Afebrile. |
| What are the findings for Eyes system for headache? | PERRL, EOMI |
| What are the findings for ENT system for headache? | No sinus tenderness, No temporal artery tenderness. |
| What are the findings for Neck system for headache? | Supple, Painless ROM, No nuchal rigidity, No meningismus. |
| What are the findings for Cardiovascular system for headache? | Regular rate and rhythm. Symmetric pulses. |
| What are the findings for Respiratory system for headache? | No respiratory distress. Breath sounds clear and equal. |
| What are the findings for Abdominal system for headache? | Soft. Non-tender. |
| What are the findings for Extremities system for headache? | No edema. |
| What are the findings for Skin system for headache? | No petechiae, No purpura. |
| What are the findings for Neurological system for headache? | Alert and Oriented x 4. Normal Speech. Motor strength 5/5 and symmetric. Sensation intact. CN II-XII intact. Normal Cerebellar exam, normal Finger-Nose-Finger (FNF). |
| What are the major DDX for abdominal pain? | Appendicitis, AAA, SBO, Cholecystitis, GI Bleed, Pancreatitis, Liver Failure. |
| What are the findings for General system in abdominal pain? | No acute distress. Afebrile. |
| What are the findings for Eyes system in abdominal pain? | No scleral icterus, No pale conjunctiva. |
| What are the findings for ENT system in abdominal pain? | Moist mucous membranes. |
| What are the findings for Neck system in abdominal pain? | Supple. |
| What are the findings for Cardiovascular system in abdominal pain? | Regular rate and rhythm. Symmetric pulses. |
| What are the findings for Respiratory system in abdominal pain? | No respiratory distress. Breath sounds clear and equal. |
| What are the findings for Abdominal system in abdominal pain? | Soft. Non-tender. No guarding, rebound or rigidity. Not distended. Active bowel sounds. No HSM (Hepato-Splenomegaly). No midline pulsatile masses. |
| What are the findings for Extremities system in abdominal pain? | No edema. |
| What are the findings for Skin system in abdominal pain? | No jaundice. |
| What are the findings for Neurological system in abdominal pain? | Alert, Oriented x 4, Normal speech. |
| What are the major DDX for SOB? | PE, CHF, MI, PNA, COPD, Asthma, Pleural Effusion. |
| What are the findings for General system for SOB? | No acute distress. Afebrile. |
| What are the findings for Eyes system for SOB? | No pale conjunctiva. |
| What are the findings for ENT system for SOB? | Airway patent. |
| What are the findings for Neck system for SOB? | No JVD. |
| What are the findings for Cardiovascular system for SOB? | Regular rate and rhythm. Symmetric pulses. |
| What are the findings for Respiratory system for SOB? | No respiratory distress. Good air movement. Breaths sounds clear and equal. No wheezes, rales, or rhonchi. Speaks in full sentences. |
| What are the findings for Abdominal system for SOB? | Soft. Non-tender. |
| What are the findings for Extremities system for SOB? | No pedal edema, Non-tender calves. |
| What are the findings for Skin system for SOB? | Not diaphoretic. |
| What are the findings for Neurological system for SOB? | Alert and Oriented x 4. |
| What are the major DDX for CP? | MI, PE, Dissection, PNA, PTX |
| What are the findings for General system for CP? | No acute distress. |
| What are the findings for Eyes system for CP? | PERRL |
| What are the findings for ENT system for CP? | Moist mucosa. |
| What are the findings for Neck system for CP? | No JVD. |
| What are the findings for Cardiovascular system for CP? | Regular rate and rhythm. No murmurs, rubs, or gallops. Strong and symmetric pulses. |
| What are the findings for Respiratory system for CP? | No respiratory distress. Breaths sounds clear and equal. No wheezes, rales, or rhonchi. |
| What are the findings for Abdominal system for CP? | Soft. Non-tender. |
| What are the findings for Extremities system for CP? | No pedal edema, Non- tender calves. |
| What are the findings for Skin system for CP? | Not diaphoretic. |
| What are the findings for Neurological system for CP? | Alert, Oriented x 4, Normal speech. |
| What is abnormal for abdominal? | Alert/Hypoactive/Hyperactive Bowel Sounds, Organomegaly, Distended, Murphy's sign, McBurney's point tenderness, Psoas', Obturator's, Rovsing's. |
| What are the signs of Appendicitis? | McBurney's point tenderness, Psoas', Obturator's, Rovsing's. |
| What must be present in a rectal exam? | A chaperone must be present. |
| What is abnormal for the rectal? | Heme positive, Abnormal stool color, Hemorrhoids, Rectal prolapse, Decreased rectal tone. |
| For Female Genital must there be a chaperone present? | Yes, there must be a female chaperone present. |
| If Normal External Genitalia, is normal then what is abnormal? | Scores, lesions, rashes. |
| If Normal Bimanual Exam, is normal then what is abnormal? | Cervical motion tenderness (CMT), Uterine tenderness, Adnexal tenderness (Ovaries) |
| If Normal Speculum Exam and Cervical os is closed and No blood or discharge, then what is abnormal? | Cervical os is open, Blood in the vaginal vault, Malodorous/thick white discharge |
| Is a chaperone needed for a male genital exam? | A male chaperone is needed for the male genital exam. |
| What is abnormal in the male genital exam? | Testicular Tenderness, Epididymal Tenderness, Testicular Edema, Testicular Mass, Urethral Discharge, Inguinal Hernia, Indwelling Catheter. |
| If Non-tender is normal what is abnormal? | Bony tenderness (Fracture), Soft tissue tenderness (Contusion), Calf tenderness (DVT) |
| Full ROM (FROM) is normal, then what is abnormal? | Decreased ROM 2 pain |
| Distal CSMT (Circulatory, Sensory, Motor, Tendon) intact, is normal then what is abnormal? | Pulse/Sensory/Motor deficits, Tendon Laxity |
| No Edema, is normal then what is normal in the extremities? | Pitting pedal edema (Trace to 4+) |
| No calf tenderness, is normal then what is abnormal? | Palpable cords/Homan's sign (DVT) |
| What are some abnormalities of the musculoskeletal/ back? | Costovertebral Angle (CVA) Tenderness, Paraspinal Tenderness, Vertebral Point Tenderness, Midline Deformities/ Step-Offs |
| If Warm (Normal Temperature), is normal then what is abnormal? | Cool to touch, Hot to touch |
| If Dry is normal then what is abnormal? | Diaphoretic. |
| If normal color is normal then what is abnormal? | Jaundice (Yellow), Cyanotic (Blue), Pallor |
| If no rashes is normal then what is abnormal? | Urticaria (Hives), Petechiae/Purpura |
| What are the abnormalities for skin infection? | Erythema, Increased warmth (Calor), Induration (Cellulitis), Fluctuance (Abscess), Purulent Drainage (Pus-Like), Lymphangitis (Spreading infection) |
| What is abnormal to skin trauma? | Ecchymosis, Contusion, Abrasion, Laceration (size in cm), Skin tear, Avulsion |
| If Alert is normal what is abnormal? | Somnolent |
| If Oriented x 4 is normal, then what is abnormal? | Disoriented to (person, place, time, or situation) |
| If Normal Speech is normal, then what is abnormal? | Aphasia (Expressive or Receptive), Dysarthria |
| If Non-Focal Neuro Exam is normal, then what is abnormal? | Any abnormal findings |
| What are the different levels of Consciousness? | Somnolent, Obtunded, Responsive to voice, Responsive to painful stimuli, Unresponsive (To voice and pain), Does not follow commands |
| What is the contradiction from motor strength 5/5 and symmetric? | Extremity Weakness (see chart below), Pronator Drift |
| What is the contradiction of sensation intact? | Hypoesthesia (decreased sensation), Numbness (absent sensation) |
| Motor 5/5 | Normal strength |
| Motor 4/5 | Very mildly weak |
| Motor 3/5 | Unable to overcome resistance |
| Motor 2/5 | Unable to overcome gravity |
| Motor 1/5 | Slight contraction, no movement |
| Motor 0/5 | Flaccid, limp |
| Reflexes 0 | Absent |
| Reflexes 1+ | Hypoactive |
| Reflexes 2+ | Normal |
| Reflexes 3+ | Increased |
| Reflexes 4+ | Clonus |
| What is a normal Babinski? | Down going toes |
| What is abnormal in the head system in a trauma exam? | Battle's sign, Raccoon eyes, Periorbital ecchymosis. |
| What is abnormal in the eyes system in a trauma exam? | Unequal pupils, Subconjunctival hemorrhage, Hyphema. |
| What is abnormal in the ears system in a trauma exam? | Hemotympanum |
| What is abnormal in the nose system in a trauma exam? | Nasal bone deformity, Epistaxis, Septal Hematoma |
| What is abnormal in the oropharynx system in a trauma exam? | Malocclusion, Dental injury |
| What is abnormal in the neck system in a trauma exam? | Vertebral point tenderness, Deformities, Step-offs |
| What is abnormal in the Respiratory system in a trauma exam? | Absent breath sounds, Splinting, Crepitus |
| What is abnormal in the Abdominal system in a trauma exam? | Tenderness, Distended, Ecchymosis |
| What is abnormal in the Rectal system in a trauma exam? | Rectal laxity (Decreased rectal tone) |
| What is abnormal in the Musculoskeletal in a trauma exam? | Pelvis unstable, Bony tenderness, Deformity |
| What is abnormal in the Back system in a trauma exam? | Vertebral point tenderness, Deformities, Step-offs |
| What is abnormal in the Skin system in a trauma exam? | Ecchymosis, Laceration, Abrasion, Skin tear, Avulsion |
| What is abnormal in the Neurological in a trauma exam? | Glasgow Coma Scale (GCS < 15) |
| What is the contradiction of Normal speech? | Tangential Speech and Pressured speech |
| What is the contradiction of Normal insight? | Denies illness/symptoms, Non-compliant with treatment |
| What is the contradiction of Normal judgment? | Suicidal/Homicidal, Hallucinations, Flight of ideas, Paranoid. |
| What is the contradiction of Normal affect? | Flat affect, Odd affect, Tearful, Anxious, Depressed, Hypomanic, Poor eye contact |
| What is the contradiction of Normal gait? | Ataxia, Antalgic |
| What is the contradiction of No nystagmus? | Nystagmus |
| What is the contradiction of Normal finger-to-nose, Normal-heel-to-shin? | Dysmetria |
| What is the contradiction of Negative Romberg's? | Positive Romberg |
| What is the contradiction of Normal RAM? | Dysdiadochokinesia |
| What is the contradiction of No Tremor? | Tremor |
| Do any patient complaints belong in the physical exam? | No |
| If a patient says their abdomen feels very painful, can you automatically document abdominal tenderness in the physical exam? | No, the information is only subjective. |
| What does PERRL stand for? | Pupils are equal round and reactive to light |
| What does AT/NC mean? | Atraumatic/ Normocephalic |
| What does NAD stand for? | No acute distress/ disease |
| If a patient has pale conjunctiva, what does that indicate? | Anemia |
| What is scleral icterus, and what does it indicate? | Yellowing of the eyes, indicates liver failure |
| Name an instrument a physician may use to closely investigate the eyes? | Slit lamp, Woods lamp |
| In which body system would you document TM erythema and bulging? | Ears |
| What is the medical term for a nostril? | Naris |
| To describe a runny nose would the doctor use the word epistaxis or rhinorrhea? | Rhinorrhea |
| What would dry mucous membranes indicate? | Dehydration |
| Why is midline bony tenderness worse than paraspinal tenderness? | Bony tenderness points towards a spinal fracture and therefore concern for spinal cord injury. Paraspinal tenderness points toward a muscle sprain or strain |
| If you saw RRR written in the cardiac exam, what do you think it might mean? | Regular Rate and Rhythm |
| Name the rhythm that the physician would hear if the patient was in A Fib? | Irregularly irregular rhythm |
| If the physician checks the pulse on the right wrist and says the pulses are fine what would you document in the physical exam? | Right radial pulse is 2+ |
| Name two peritoneal signs in the abdominal exam? | Guarding, rebound, tenderness, rigidity |
| What abdominal exam sign is indicative of Cholecystitis? | Murphy's Sign |
| If you documented NAD in the constitutional section, would you be contradicting yourself if you wrote "There is mild respiratory distress" in the pulmonary exam? | Yes |
| If you document "There is right pronator drift" in the neurological exam, can you also document "no focal neurological deficits"? | No, contradiction |
| What is the medical term for "swollen lymph nodes"? | Lympghadenopathy |
| Spell the medical term for Hives? | Urticaria |
| A mother states her child has been extremely tired and drowsy recently; based on that, can you document lethargic in the child's physical exam? | NO |
| What would you guess TTP means? | Tender to Palpation |
| Would you document RUE strength 3/5 under the Neurological or Extremities section? | Neuro |
| What is fluctuance a sign of? | Abscess |
| What is CVA tenderness? | Flank tenderness. Tenderness over the kidney. |
| What is bony tenderness a sign of? | Bone deformity, fracture, or injury |
| What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician? | Female chaperone present |
| What would a Guaiac positive stool sample diagnose? | GI Bleed |
| If the doctor takes one finger and presses in a specific spot in the RLQ. What is the name of the finding they are investigating? | McBurney's point tenderness |
| Is the Glasgow Coma Scale (GCS) associated with Trauma pts or Medical patients? | Trauma |
| In the psychiatric exam, what do SI and HI stand for? | Suicidal and Homicidal Ideations |
| In the neurological exam, what does normal gait mean? | walking normally |
| Point to the general area of the body that the CN control? | Face |
| What does DTR stand for? | Deep tendon reflex |
| What section of the neurological exam would you document normal finger nose test and normal heel to shin? | Cerebellar/ Coordination |
| What does A& O x3 Mean? | Alert and oriented to person, place, time |
| What procedure is associated with a laceration, but not an abrasion? | Laceration repair, sutures |
| What is the difference between an abrasion and a laceration? | Laceration is an incision in the skin that typically need sutures. Abrasion scrape of the skin. |
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ehachez77