PE Documentation

Question 1

Vitals

Answer 1

Comment on vitals (can say within normal limits if they are)

Question 2

Head

Answer 2

Normocephalic, no palpable abnormalities of scalp, cranial bones, or maxillary/frontal sinuses

Question 3

Eyes

Answer 3

brows, lids, lacrimal ducts are symmetric and without inflammation; conjunctivae clear; PERRLA, EOMI; fundoscopy reveals vessels without abnormality, fundus margins clear

Question 4

Ears, Nose, Mouth, and Throat

Answer 4

no lesions or edema of external ear; tympanic membrane is clear with landmarks preserved; external nose and nasal membranes/inferior turbinate are clear; lips, oral mucosa and pharynx are free of lesions or edema

Question 5

Neck

Answer 5

neck is supple/range of motion full; trachea is midline, no venous distention; carotid pulsations 2+/ 4 and without bruits; no palpable masses or adenopathy; thyroid is symmetric and of average size and free of nodules

Question 6

GI/Abdomen

Answer 6

No abnormality of abdominal contour or venous pattern; bowel sounds active in 4 quadrants; no aortic or renal bruits; abdomen soft and nontender on palpation; no masses or organomegaly

Question 7

Lymphatic

Answer 7

no abnormal lymph nodes in neck, axilla or inguinal area; no upper or lower extremity edema

Question 8

Musculoskeletal/Structural (Spine and Extremeties)

Answer 8

range of motion in axial (cervical, thoracic, lumbar) and appendicular skeletons is maintained; no joint deformities or swelling; no thoracic or lumbar temperature changes, erythema, sweating, muscle spasm, tenderness, or vertebral rotation; no scoliosis

Question 9

Skin and Subcutaneous

Answer 9

No abnormal skin lesions, rashes, ecchymoses

Question 10

Neurologic

Answer 10

cranial nerves II-XII intact; no sensory deficits; cerebellar function maintained; gait is stable; deep tendon reflexes and upper and lower extremities symmetric 2+/4; muscle strength in all major muscle groups in upper and lower extremities is 5/5

Question 11

Psychiatric

Answer 11

No sign of cognitive impairment or disordered thought; affect appropriate

Question 12

Constitutional

Answer 12

Pleasant, no acute distress, answers questions appropriately

Question 13

Cardovascular

Answer 13

Regular rate and rhythm; S1 and S2 preasant without any murmurs, gallops, or rubs

Question 14

Respiratory

Answer 14

No evidence of respiratory distress, lungs are clear to auscultation; thoracic excursion full and symmetric

Question 15

List the areas of the objective exam

Answer 15

• Vitals
• Constitutional
• Cardiovascular
• Respiratory
• Head
• Eyes
• Ears, Nose, Mouth, and Throat
• Neck
• GI/Abdomen
• Lymphatic
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric

Question 16

List areas for OMT (aka. Somatic dysfunction of…)

Answer 16

• Head
• Cervical
• Thoracic
• Lumbar
• Sacrum
• Pelvis
• Lower extremities
• Upper extremities
• Ribs
• Abdomen/Viscera