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Scribe Series: PE

Hello again!

I wanted to post this awhile ago but couldn’t figure out the best way to present it. So I’m hoping to be able to lay this out in a relatively easy way for you to follow and understand. And hopefully, help fill you in where you feel you are lacking.

In all honesty, I probably won’t be able to do all that. But hey, I’ll try!

The systems:

The PE, or physical exam, is broken into systems just like the ROS is. The PE is much more detailed than the ROS, as you can have an infinite amount of exam findings. Plus, the ROS is just to discuss symptoms of the patient. But the PE is to describe what the physician actually finds. This goes into the objective portion of the chart.

Systems include:

General Appearance
Head
Eyes
ENT
Neck
Cardiac
Lungs
Abdomen
Genitourinary
Rectal
Breast
Musculoskeletal
Back (sometimes just lumped in with MSK)
Extremities (sometimes just lumped in with MSK)
Skin
Psych
Lymph

Now there may be some different categories depending on the EMR being used. Additionally, different specialities will use different categories, or selective categories for what benefits or fits into that specialty.

For example, a cardiologist may only use General, Neck, Cardiac, Lungs, and Extremities in majority of their notes, and then add more if needed. But for Family Practice or Internal Medicine, they will use several of the above. Typically a full exam will have 12 systems that are evaluated.

The other thing you need to remember, is a well visit or first patient encounter for general medicine will have more systems that are needed to be examined than a brief return visit for a problem focused exam.

I really wish I could remember how many bullet points were needed for problem focused versus detailed exams. I think it is 9 and 18, but don’t quote me on that.

Touch versus no-touch exams:

No-touch exams are a way for medical providers to use other senses such as sight, smell, and hearing, (things outside of touch) to add observations about a patient’s current health state.

They fill out the chart to help with both a better picture of how the patient is doing at the time of evaluation and eventually for billing. But doctors mainly use it to include a more rounded picture of how the patient was during presentation. Billing is more of a hospital/clinic thing and/or a scribe may be required to keep track of those things.

Examples of this include: Alert, able to converse without difficulty, slurring speech, garbled speech, smells of alcohol, breath smells fruity, face symmetric, head normocephalic and atraumatic, normal respirations/no respiratory distress, no acute distress, moves all extremities without difficulty, able to move (i.e. arm or neck) with some ROM (range of motion) during conversation, good color, no overt skin rash noted, etc.

You get my point. These are all things that you can see/smell/hear, usually within a few seconds of walking into a room with a patient.

A touch exam is what you would typically think of when a PE is done. It is more in depth and includes things like listening to heart and lungs, palpating the abdomen, doing ROM tests for extremities, and doing a more thorough skin exam.

The breakdown:

There will usually be an additional place on the PE to note that vital signs were checked. It’s a really bad thing if the vitals aren’t entered into the chart OR weren’t reviewed by the provider. In every case of seeing a patient, physicians/nurses/PA’s all check the vital signs. Whether they mention it or not. This is a checkbox that serves to say they did check it, even though everyone does…

If your provider does not check it with every patient you have bigger problems my dear.

General Appearance: This is the first part of every PE. It serves to set a general picture of the patient. Is it good? Is it bad? Do they look relatively normal and healthy?

You get my point.

What sort of things are found under this system? Things to include are mostly observations. A lot of this can be obtained when you first walk into a room and you see a patient either in the chair, on the exam table, in the hospital bed, or walking around the room. It helps illustrate if a patient is sick, in distress, or doing just fine.

Head: This section of the chart is usually pretty small. Unless of course there is a head trauma. This section will usually always have normocephalic & atraumatic checked. Again, unless there is a head trauma. In which you would describe any changes or trauma noted to the head (as a whole) and face.

Eyes: Normally you would find things like PERRL and EOMI checked for most patients. But basically you are putting the appearance of the eyes here (if normal or abnormal) and the findings if a specialized eye exam is done.

ENT: This includes everything ears, nose, and throat. External appearances, and a closer inspection of each area of the head.

Neck: Mainly if they can move it. So does it look supple? (Basically can it move without difficulty). Is there restricted ROM? Why is there restricted ROM? This may also have external appearance and potentially lymph gets added in here too.

Lymph: You have lymph everywhere. The major areas of lymph nodes include the face, neck, supraclavicular/axillary area, and groin. But you literally have these suckers everywhere. Majority of the time you may just use note if they do or don’t have cervical lymphadenopathy, which can be lumped under neck. Other times you will have a more in-depth exam finding or evaluation.

Cardiac: Everything to do with the heart. You can also place anything pertaining to the cardiovascular system, including pulses, warmth, color, etc.

Lungs: Everything to do with the lungs. This is usually just an auscultation exam. But may also include things like appearance of chest, tenderness of the chest wall, and any speciality tests. If the additional are added, then it would fall under “chest” heading.

Abdomen: Full abdominal exam/findings. May include kidneys/flank area as well. Same thing applies: appearance, percussion, auscultation, and tenderness.

GU/rectal: This is not typically done on most patients. For obvious reasons. Nobody likes their nether-regions being examined unless they have an issue OR it is a general well exam that needs to be done for health screening purposes. Because it is not normally included, you will likely have to add this section to your chart. (Unless you work in a gynecology or prostate clinic).

Breast: Same thing, this is not normally an exam that is done. Except if you work in a women’s clinic or gynecology clinic or unless it is a maintenance exam/screening exam or they have a specific complaint. You will likely need to add this into the PE section.

Musculoskeletal (will include back and extremities here): There is a lot you can put here. ROM (range of motion), warmth/cool to touch, pulses, how does the skin look? Strength, reflexes, sensation. All of that.

Skin: Usually you will just put intact, of good color or something like that UNLESS neither of those are true. Things like rashes are the biggest thing that you put under skin. You can also put isolated trauma injuries here such as lacerations, burns, etc.

Psych: This will not be done in every case either. Things like depression screenings, if someone is anxious, if their affect is off, paranoid, delusional, hallucinating, all that fun stuff. Unless of course you work the psych unit in the ER or are working in a psychiatry office.

But you will figure out with each exam what your provider you work with likes in each section/their specifics for their exam. This is just a general guide.

Example PE (normal):

I got this example from https://www.soapnote.org/general/general-adult-physical-exams/ and added a few things. Your templates will vary greatly depending on who you work with and what specialty you are in. These are just examples. Honestly, they go a little too in-depth for some of these if you ask me...

GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.

HEAD: normocephalic. Atraumatic.

EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.

To be honest I’m pretty sure you need to do an evaluation with an ophthalmoscope for fundoscopic findings, so should not be included in every exam…

EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.

NOSE: No nasal discharge. External nasal appearance appears symmetric. Turbinates pink, moist, non-boggy.

THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Mallampati score of (1- 5/5).

NECK: Neck supple, non-tender without lymphadenopathy, masses, or thyromegaly.

CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. RRR (regular rhythm and rate). There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.

Carotid bruits can also go under neck.
Cap refill can go under skin as well.
Extremity findings can also go under MSK or extremity (if this is a specified section on the exam).

LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Normal appearing chest. No chest tenderness.

ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.

You may also see this as S/NT/ND, but this is not always an approved abbreviation.

MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait.

Gait can also go under neurological exam.

BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm.

See the similarity here with the MSK exam? Most of the time this is included in MSK.

EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities.

Remember, some of this can be part of the cardiovascular exam but you see it in the extremities. Other findings are just MSK related. This is usually under MSK.

LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity.

Okay honestly, I feel like the website I’m getting this information from is beating a dead horse. BUT, you can see again that you can move findings to different areas of the chart.

NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.

YOU MUST write the cranial nerves (CN) in Roman numerals. If there is an issue with a cranial nerve, you can write “CN II-XII intact except for CN III” or whichever CN is the issue.
Reflexes can go under extremities as well. Same with sensation.

SKIN: Skin normal color, texture and turgor with no lesions or eruptions.

PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal.

I want to remind you all that if aspects of the chart are not actually evaluated/examined DESPITE being in your providers "normal template" you need to take it out. No touch findings/evaluations can usually be left in unless they are contradictory. In general, if something is abnormal or contradictory to what is in your general template you need to change it to the correct exam findings.

Dictation:

Okay. You will receive the PE in one of three ways.

You will be dictated to in the room while the exam is occurring. As a new scribe (or if your provider is just particular AF) you will receive all the normal and abnormal findings. If you are a more advanced scribe you will likely just receive the abnormal findings.
You will be dictated to in their office or a dictation room where several providers hang out between patients. Same thing applies as above.
You are an experienced scribe and they just assume you know what you are doing. They may give you just the abnormal findings. They may completely forget that you are a scribe and you didn’t actually do the exam yourself, and you may have to prompt them for abnormal findings.

Since you are being dictated to, you will need to improve your listening and typing skills as a scribe. This is critical! You will also need to make sure you have a good shorthand so you can go back and rewrite/properly add in the examination. As a scribe (especially a new one) you haven’t quite grasped what is normal and abnormal yet. So make sure you are getting all the details so you can accurately put this information in the chart.

Once you have all the information, make sure you are removing contradictory elements in your PE. I can’t stress that enough. I have seen countless scribes forget to remove the contradictory information. If you aren’t sure about something, Ask!

Common Words/Abbreviations:

I will put some common words/abbreviations here. There are a lot. So much so that universities will try to convince you to take a medical terminology course.

Don’t do that.

It is seriously a waste of time. Google will help you find all of these and it is free!

And honestly, there is no shame in looking up a word you can’t remember or you aren’t quite sure is correct. Better to double check than use the wrong word. No one is going to know. Unless of course you are being pimped. Then you are on your own there bud…

Here is a PDF of what is approved for the NBOME: It starts on page 17.

A&Ox3: Alert and Oriented (x3) or to person, place, and time. You may also see A&Ox4 which is the same as above but add event.

VSS: Vital signs stable.

NAD: No acute distress.

LMP: Last menstrual cycle. You may also see LKMP: which is last known menstrual cycle. For those of you with out vaginas the cycle starts on the first day you bleed. A typical “regular” cycle is 28 days, but there is a lot of variation with this.

NC/AT: normocephalic, atraumatic.

PERRL: pupils equal, round, and reactive to light (sometimes will have an A at the end which stands for accommodation)

EOMI: extra ocular movements intact.

EAC: external auditory canal.

LAD: lymphadenopathy. (I personally hate using this one).

RRR: Regular rate and rhythm

NSR: Normal sinus rhythm

CTAB: Clear to auscultation bilaterally

ROM: Range of motion

CN II-XII: Cranial nerves 2-12

abd: abdomen

CVA (has 2 meanings): costovertebral angle (or flanks) AND cerebrovascular accident (stroke)

HTN: Hypertension

DM: diabetes mellitus

NIDDM: Non-insulin dependent diabetes mellitus

IDDM: insulin dependent diabetes mellitus

CHF: Congestive heart failure

COPD: Chronic obstructive pulmonary disease

CABG: coronary artery bypass graft. (if you hear this it will sound like “cabbage”. Do not write that. They are never talking about the vegetable cabbage.)

JVD: Jugular Venous Distension

R/O: rule out

WNL: within normal limits

LFT’s: Liver function tests

MVA: Motor vehicle accident.

Cspine/Tspine/Lspine: Use one on their own, not listed like this. Stands for cervical spine, thoracic spine, lumbar spine.

PE (has 2 meanings): Physical exam OR pulmonary edema. You need to be able to distinguish in what context you are using.

DVT: Deep vein thrombosis

URI: upper respiratory infection

I&D: incision and drainage.

There are so many. But hopefully that is a start. A lot of these should sound somewhat familiar if you’ve ever spent time in a medical setting.

This website has a few good medical words with definitions if you want to check it out: Vitality Medical.

Des Moines University has some helpful prefix and suffix information as well.

Hopefully this was somewhat helpful to a few of you! It’s hard to remember all of the terms I learned as a scribe because it was so long ago. If I can keep track of what I see again I will try to make another list, but no promises.

Cheers!

What’s In My Locker?

Hello MedHatters!

This week I wanted to share what I had kept in my locker as a first year. I will go over what was super useful (to me), what I would have replaced, and what I wish I would have had. Hopefully this helps guide you if you plan to use your locker as a first year student!

Now, I know most schools don’t have assigned lockers. On the KC campus, students have access to lockers that they can sign out. They need to bring their own locks and at the end of the year have to give up the locker. And once there are no more, you can’t get a locker. Since there are so many students on the KC campus (its not just medical students on that campus), getting a locker at any other time after the very beginning of the school year can be hard. At some schools you don’t have a designated space. In Joplin, we are a small enough campus that we all have designated lockers assigned to us. Each student is assigned one and encouraged to use it so our stuff isn’t all over the place. They come with locks and are given to you during orientation. It is yours for the first 2 years.

Currently, we have enough lockers that each club also gets a locker. So I have 2: my personal one and one for MAOPS (I’m on the board for this club). I’m sure once more students are on campus they will switch to not having club lockers. But I’m not sure how long that will take.

And no. Not everyone uses their locker. So don’t feel obligated to really use yours!

What I Had in My locker:

A blanket. I got a lot of flack for this at first. But you know what? It gets really cold on campus no matter what time of year it is. And I’m the type of person that is always cold (or gets cold easily). If I have to be here for class or to study, I want to be warm.
Lots of slipper socks. I have many pairs. It’s nice to keep my feet warm and I don’t have to wear shoes.
Gallon zipper bags. This was helpful for anatomy. Either to put my dirty/smelly scrubs in so it wouldn’t stink up my locker or to put my iPad in to take into lab with me! Definitely a must as a first year student for anatomy if you plan to bring your iPad into the lab.
Usually an anatomy atlas. I have Dr. Olinger’s pictured because it is easier to carry around, but I believe Netter’s stayed in my locker.
Spray/lotion. I would use this to help mask the awful dead body smell if I couldn’t go home and shower right away.
My “tool” bag. This had all the instruments that were “required” for first years. Honestly I did not need all of these… But I kept them in a bag in my locker since I needed to use most of them while on campus.

Not pictured: My otoscope & stethoscope. They are currently packed for my Kenya trip!

For the blanket and slipper socks, I would periodically take them home and wash them and bring them back. I did a lot of walking around in those socks while on campus and they did get dirty somewhat fast since I used them so often. But since I’ve dedicated those items to just use at school, its not like I was using them in my home. But don’t worry; they definitely were washed many times during the year!

What I had that I would Change:

I originally had my white coat in my locker. But turns out there wasn’t a ton of space for this. Also, I have a bottom locker. There were definitely times where I would hear people from top lockers spilling coffee, juice, energy drinks, etc and it would leak down to the bottom locker. Not a big deal most of the time, but I didn’t want that happening to my white coat.
I also originally had coffee pods in my locker. This is a great idea, except I got really cheap and nasty Walmart ones and turns out I didn’t really drink them because they were gross. Definitely recommend getting slightly better quality ones (we have 2 Keurigs on campus). OR some friends had instant coffee in their locker.
Sometimes I would put a spare change of clothes in my locker. I stopped doing that though simply because I live less than 5 minutes away from campus and could easily go home and shower or change and come back. For students who plan to spend longer days here, it may be a good idea to keep an extra pair of scrubs or extra clothes to change into.

What i wish i had:

Ibuprofen. Oh lord I needed this more often than I can remember. I would always tell myself to put some in my locker and then forget. Luckily there was always a classmate on campus that had a bottle of it.
Snacks. This is another one I wish I had. Sometimes I would just want something salty and snacky and wouldn’t have any. Some classmates had large bulk bins of snacks like this in their locker.

And that is basically it. Now, I spent a lot of time on campus. I mean A LOT. But if you aren’t one to really spend time on campus, then you probably don’t need to have this much stuff in your locker. E really only kept his tools/instruments in his locker. Sometimes he left his white coat. But really he just needed a place for his stuff during anatomy lab.

Bonus! What i kept in my car:

Yup, I went there.

I usually kept an extra jacket in my car. Mostly because I knew I would be cold during lectures or while studying even if it was balls hot outside. So I would just keep it in there to grab on my way into campus or if I needed to run out and grab it.

I also kept my Moore’s book in my car. Why? Well that thing is huge. And since we needed it for most anatomy courses (or at least parts of that book) I wanted to have it on hand. What if I needed it on campus and it was at home? What if I needed it at home and I kept it in my locker? You see my dilemma? So I kept it in my car. That way I could run out and grab it if I needed it.

Occasionally my blanket would hangout in my car if I would have it in class and didn’t want to drag it back into my locker before leaving. But those were the two main things that I kept in my car during first year.

Double bonus! what do i actually need for the instruments?

Now, I’m sure the school won’t be happy with me saying this. But like, you really don’t actually use all those tools. There will be third years who sell them at much cheaper but still somewhat pricy because most of those instruments are new.

Some people get much cheaper versions off of Amazon.

A lot of students just used other student’s stuff because they didn’t bother to buy it.

And then you have people like me that bought the tools but really didn’t use most of them (at least for first year).

Stethoscope: Yes. Yes you need this. You will use this the most. I had a cheaper one that an ex left me (he was an EMT for awhile) and I somewhat wish I would have gotten a slightly better one. But, I didn’t want to spend anymore money.
Reflex hammer: Yes you do use this. If you are going to buy this, get the rubber one, not the plastic one. I promise it will be less painful given the amount of times you practice taking reflexes with the rubber one. BUT! They do provide this one during your SP encounters. You may not be provided this during score 1 in second year though.
BP cuffs: Um, kinda. I know you need this more for second year for score 1. We needed it to practice on one another before our vital signs competency in first year and that is basically it. You get tested on the mannikins that have an attached BP cuff for this competency. So, you don’t all need to buy one since you are just using it for practice in first year. Also, all the rooms in Joplin have BP cuffs for your SP’s.
Otoscope: Honestly we just used this during one or two labs. We have attached ones in the SP rooms to use. Pretty sure you need it for second year though for score 1, but first year we didn’t do much with it.
Ophthalmoscope. Same thing. we just used it during labs. All the SP rooms have one in Joplin. Will likely need it for score 1 in second year.
Eye chart: Only used this during neuro lab and the first instrument lab in first year. They provided it during SP’s. Not sure if this is needed in second year? Will let you know.
Tuning fork: Same thing. Only used it during those 2 labs like the eye chart. It was provided during SP’s. Not sure if we need this in second year yet.
Otoscopy bulb: WE DID NOT USE THIS ONCE. Not at all. Really not sure why we needed to buy this. Maybe we will use it in score 1 but my god I’m not even sure we used it in the intro to instrument lab.

And I think that’s it for the instruments. A lot of what is on your list you will be expected to have for score 1 in second year (like I keep repeating). Even then, I’m not sure how much you will use. But sometimes when you do mass clinics like that you aren’t all doing it at the same time. So you may get away with just borrowing each other’s stuff OR borrowing from a first year below you.

So, you decide if it is worth buying all of this in your first year. You may get away with not needing it much and can borrow from other students. By the time you get to 3rd and 4th year, all of this will be provided by your clinics.

Hope this was helpful. Cheers!