HENT/NECK
When there is built up ear wax in the ear canals, occasionally obstructing view of the TMs
What is cerumen impaction?
Abbreviation for regular rate and rhythm
What is RRR?
What a provider listens for when they place a stethoscope on a patient's stomach
What are bowel sounds?
SMAC provider with smartphrases for most, if not all, ortho exams for you to go through together after OV
What is the UF SHCC Scribe Manual?
This is updated pretty regularly but things change so if a provider ever tells you something different from the manual, clarify with them and if so, make a comment on the doc in the corresponding section
Physical exam description for "white stuff," either on the tonsils or the throat
What is exudate?
When a patient's HR is elevated above normal limits, >100bpm
What is tachycardia?
The opposite is bradycardia! (<60bpm)
What providers are checking for when they feel a patient's neck but DO NOT ask them to swallow
What is cervical lymphadenopathy (and tenderness)?
What are patellar reflexes?
PE when a provider sees a patient (for any amount of time and any reason for visit) but does not actively perform an exam
What is an observational physical?
Physical exam word for acne, popular with Dr. Grooms
What are comedones?
Smartphrase to use for Mrs. Freshwater when she listens to a patient's lungs
What is .freshlung?
When a provider checks for lymph nodes near the groin
What is inguinal lymphadenopathy?
You mark this negative when a patient is able to walk without any deformity, difficulty or discomfort
What is abnormal gait?
Section of the physical exam where we include any general observations about patient from OV, such as appearance, speech/affect, consistent actions, build, etc.
What is the constitutional comment box?
What a provider checks for when they tap a patient's forehead (frontal) and cheekbones (maxillary) bilaterally
What is sinus tenderness?
The three pulmonary symptoms we mark negative for MOST providers when an exam is normal
Wheezes, rhonchi and rales
Except for Dr. Grooms-- with her, you can just mark breath sounds normal as she feels that having all of them is too repetitive.
What a provider checks for when they ask a patient to take a deep breath and presses down on either side of their abdomen
What is hepato- and spleno-megaly (AKA hepatic and splenic enlargement)?
When a provider checks for reflexes on a patient's elbow
What are bicep reflexes?
When a provider performs an exam on ANY and/or ALL parts of the body but does not tell you about any findings, we assume the exam is
This is true for most providers. If there is something abnormal, THEY WILL TELL YOU. If they do not say anything regarding a body part they examined, it is safe to assume there were no abnormal findings-- MARK THEM NEGATIVE IN THE PHYSICAL. Some exceptions are Ms. Lochridge, who will tell you even if findings are normal.
The area of the body that a provider is checking when they put both hands on the anterior aspect of the neck and ask them to swallow
What is the thyroid?
Usually checks for thyroid mass, tenderness and thyromegaly (the only blocks under thyroid anyway)
When a provider checks a patient's pulse at their wrist
What is a brachial pulse?
What a provider is checking for when they bump/tap a patient to the R and L of their mid-back
What is (R/L) CVA tenderness?
Usually done for kidney(-related) concerns, such as UTI, kidney stones, pyelonephritis, etc.
What a provider is testing when they ask a patient to smile, shrug their shoulders, frown, raise their eyebrows, tightly shut their eyes, etc
What are cranial nerves 1-12?
What you do if you're unsure about a finding/body part/side/word spelling/exam
What is ask your provider?
SHCC providers are so nice please feel free to ask if you're ever unsure-- better safe than sorry!