physical exam

Directional Terms:

All terms describing directions and locations refer to the human body in anatomical position.

The following skeleton is in anatomical position, standing erect with arms at sides and palms

•       Fowlers – an inclined position obtained by raising the head of the bed about 60 to 90 cm (may be used to release strain on muscles/improve breathing)

•       Trendelenburg – a position in which the patient is placed in the supine position and the stretcher is inclined at 30-45 degrees so that the legs are elevated over the head

Physical Examination Techniques:

The clinician will use the following four techniques to perform the physical examination:

•       Inspection – visual examination of the body

•       Palpation – the clinician uses their hands to examine the patient o Tenderness – pain when a clinician palpates an area (objective way to describe pain)

•       Percussion – tapping over different areas of the body 

•       Auscultation – listening with a stethoscope to the heart, lungs, abdomen, and blood vessels

Using the four techniques, clinicians also assess for symmetry in various systems/body areas

•       Symmetry – equal on either side of the body, i.e., symmetric strength in all extremities THE GENERAL SURVEY/GENERALIZED APPEARANCE

The general survey/generalized appearance is an overall review or first impression that a clinician has of a patient’s well-being. It is a visual observation and encompasses appearance, body structure/mobility, and behavior.

The clinician will give his/her impression of the patient’s general appearance and description of any distress. Some examples of distress types include painful distress, respiratory distress, etc. The types of distress are described by severity (e.g., mild, moderate, and severe).

For Example:

GENERALIZED APPEARANCE: Patient is resting comfortably in an upright, seated position on the hospital bed.

For Example:

GENERALIZED APPEARANCE: Patient is alert, awake, and in mild respiratory distress.

Ask the clinician for his/her impression of the patient’s general appearance. Do not make assumptions!

Physical Exam Findings: 

•       Affect – the emotional tone a person expresses (e.g., blunted, flat, inappropriate, labile)

•       Anasarca – generalized body edema

•       Alertness - level of consciousness ranging from fully aware to comatose (e.g., patient is alert and awake)

•       Cachexia (adj. cachectic) – physical wasting with loss of weight and muscle mass

•       Ill-appearing – appears sick 

•       Lethargy (adj. lethargic) – a decreased level of consciousness marked by abnormal drowsiness, sluggishness, and/or apathy

•       Somnolent – sleepy, drowsy

•       Malaise – generalized feeling of discomfort, illness, or lack of well-being 

•       Mood – a conscious state of mind or predominant emotion

•       Obese – excessively overweight

•       Obtunded – mentally dulled, somewhat confused, and slow to respond

•       Orientation – awareness of four possible dimensions (person, place, time, and situation); typically, clinicians will evaluate for awareness of person, place, and time, ex: “patient is oriented x 3”

INTEGUMENTARY (SKIN)

Physical Exam Findings:

Skin Appearance:

•       Skin color – pink, cyanotic, pale, jaundiced  o

•       Cyanosis (adj. cyanotic) – bluish discoloration of the skin or mucous membranes due to deficient oxygenation of the blood 

o   Erythema (adj. erythematous) – redness  o

o   Jaundice – yellow discoloration caused by increased bilirubin o

o   Pallor (adj. pale) – deficiency of color especially of the face 

•       Temperature – hot, cold, cool, warm o

•       Moisture – dry, diaphoresis 

§ Diaphoresis (adj. diaphoretic) – excessive sweating

Many templates will indicate that skin is dry (a normal finding). If the clinician dictates a patient is diaphoretic, ensure “dry” is removed to avoid contradiction and internal discrepancy. 

•       Turgor (elasticity) – the skin’s ability to change shape and return to normal. To check for skin turgor, the clinician can grasp the skin between two fingers so that it is raised for a few seconds and then released. 

o   Tenting – quality of the skin to slowly return to normal; indicates poor turgor, common finding related to dehydration. 

Skin Abnormalities:

•       Abscess – localized accumulation of pus surrounded by an inflamed area o Pus – an opaque fluid, formed as part of an inflammatory response 

•       Ecchymosis (adj. ecchymotic) – a bruise; a discoloration of skin caused by hemorrhaging under skin or mucous membranes 

•       Fluctuance (adj. fluctuant) –a wave-like motion caused when a fluid-filled structure is palpated; being moveable and compressible 

•       Induration (adj. indurated) – abnormally firm/hard area under the skin

•       Lesion – area of abnormal tissue changes due to damage or disease  o

•       Macule (adj. macular) – a flat patch of skin that is altered in color (e.g., freckles, petechiae)

o   Papule (adj. papular) – an elevated patch of skin that is altered in color (e.g., mole) o Maculopapular – a lesion that exhibits characteristics of a macule and a papule o Nodule (adj. nodular) – a small mass of rounded or irregular shape o

o   Pustule (adj. pustular) – a vesicle filled with pus (e.g., pimple) o

o   Vesicle (adj. vesicular) – small abnormal elevation of the outer layer of skin enclosing a watery liquid 

o   Petechiae – macular rash characterized by small, pin-point red dots; caused by localized hemorrhage (broken capillaries); petechiae can be a symptom of leukemia, idiopathic thrombocytopenia (ITP), or meningococcemia as well as other conditions including vomiting 

o   Purpura – purple discoloration of skin caused by minor hemorrhage of blood vessels; larger than petechiae (may be palpable)

o   Ulcer – an open sore of skin or mucous membrane accompanied by inflammation and the disintegration of tissue; can be caused due to a lack of mobility, which causes prolonged pressure on the tissues

§  Decubitus ulcer – an ulcer caused by prolonged pressure on the skin, often caused by lying in one position for a prolonged period; also known as a pressure ulcer, pressure sore, or bedsore; requires documentation of the site of the ulcer, laterality, and staging (I-IV)    

Decubitus ulcers are commonly present on arrival and need to be documented in the physical exam as well as in the diagnoses they are an existing condition for a patient.

o   Urticaria (adj. urticarial) – area of the skin that is raised, reddened, and typically itchy due to allergic reaction; also referred to as hives or wheals

 Confirm the arrangement of the lesions with your clinician. Common arrangements include linear, clustered, annular (circular), arciform (arc), or dermatomal.

§  Dermatomal – follows along the sensory nerve root/dermatomes (e.g., Herpes Zoster/Shingles)

•       Lymphangitis – inflammation of lymphatic vessel, characterized by lymphangitic streaking

o   Lymphangitic streaking – red streaks on the surface of the skin that trace from the infected area to the nearest lymph node 

•       Purulence (adj. purulent) – consisting of pus

•       Suppuration (adj. suppurative) – producing or causing the production of pus

•       Wound - an injury to tissue caused by a cut or other impact o

•       Abrasion – wearing away of the upper layer of skin due to friction (e.g., rubbing or scraping)

o   Avulsion – tearing away (e.g., flap of skin) 

o   Contusion – a bruise o Laceration – cut/tear of the skin 

o   Puncture – injury caused by a sharp, narrow object piercing the skin

 Confirm the following with the clinician: the size of the wound in centimeters, the area affected including laterality, whether a foreign body is visualized on examination, and if there is nail involvement (if applicable). For lacerations, also indicate the length and depth of the laceration in centimeters, the shape, the complexity, and the condition (i.e., contaminated; requirements debridement).

Common Complaints and Conditions:

•       Allergic reaction – a condition in which the immune system responds to a foreign substance; symptoms range from mild to severe, including urticaria, pruritis, congestion, rash, etc. 

o   Anaphylaxis – a life threatening, severe allergic reaction which can include diffuse erythema and urticaria, generalized edema, upper airway obstruction due to swelling of the oropharynx, respiratory distress, hypotension, and abdominal pain

•       Pruritus (adj. pruritic) – itching 

•       Burn – an injury to the skin caused by thermal, chemical, electrical, or radiation energy

 For burns, confirm the size, location, description, and the percentage of the Total Body Surface Area (TBSA) affected with the clinician.

•       Cellulitis (adj. cellulitic) – a bacterial infection of the skin and subcutaneous tissue; the extremities, especially the lower legs, are the most common sites; adjacent soft tissue may be involved

•       Herpes Zoster (Shingles) – a painful, blistering rash caused by the varicella-zoster virus; appears in a dermatomal fashion as it infects and inflames nerves along a dermatome 

•       Paronychia – inflammation or infection of the tissues adjacent to a nail; may require draining

•       Scabies – contagious skin disease due to an infestation of the scabies mite; symptoms include intense itching and excoriated, erythematous papules

•       Subungual hematoma – collection of blood underneath the nail; may require draining

•       Tinea Capitis – fungal infection of scalp

•       Tinea Corporis – ringworm of the body, superficial fungal infection

•       Tinea Cruris – fungal infection of genital area

•       Tinea Pedis – ringworm of the foot, commonly referred to as athlete’s foot

HEAD AND FACE

Structures Related to the Head:

•       Bones of the Skull o

•        Frontal – forehead

o  Parietal – sides and roof of the skull o Occiput/Occipital – back of head (not pictured)

o  Temporal – sides and base of the skull

o  Zygoma – cheek o

o  Maxilla – upper jaw  o

o  Mandible – lower jaw o

o  Mentum – chin 

•       Temporomandibular Joint (TMJ) – hinge that connects the mandible to the temporal bones

•       Orbits – eye sockets

o  Periorbital – area surrounding the eyes

Structures Related to the Brain:

•       Meninges - 3 membranes that envelop the brain and the spinal cord; their primary function is to protect the central nervous system      o

•       Dura mater – closest to skull and vertebrae o

•       Arachnoid mater – middle “cushioning” element

o Pia mater – delicate outer membrane that adheres to the brain and spinal cord

•       Cerebrospinal fluid – acts as a buffer for the brain, providing basic mechanical and immunological protection to the brain inside the skull; occupies subarachnoid space

Physical Exam Findings:

•       Normocephalic – head is of normal shape and size for the person’s age (commonly dictated as normocephalic-atraumatic in the absence of trauma)

•       Battle’s Sign – mastoid ecchymosis (ecchymosis behind the ear) associated with trauma/skull fracture, especially basilar skull fractures

•       Raccoon Eyes – periorbital ecchymosis associated with basilar skull or orbital fracture(s)

Common Complaints and Conditions:

•       Concussion – a traumatic brain injury with a temporary loss of brain function because of a violent blow, shaking, or spinning 

•       Encephalopathy – any disease of the brain that may alter brain function or structure

•       Intracranial Hemorrhage (ICH) – bleeding within the brain issue that typically occurs after head trauma or rupture of an aneurysm; there are four main types of ICH:

o   Epidural Hematoma – accumulation of blood between the skull and the dura mater o Intracerebral Hemorrhage – accumulation of blood in the functional tissue of the brain 

o   Subarachnoid hemorrhage – accumulation of blood into the subarachnoid space o Subdural Hematoma – accumulation of blood between the dura and arachnoid mater

•       Migraine – episodic attacks of moderate to severe headaches which can be associated with symptoms such as nausea, blurred vision, and sensitivity to light (photophobia), sound (phonophobia), or head movement

EYES

•       External structures o Lids – upper and lower folds of skin that cover the eye when closed

o Lashes – short, curved hairs on the edge of the lids to protect the eye from small particles such as dust

•       Conjunctivae – paper thin covering the sclera

•       Cornea – transparent part of the eyeball that covers the iris and pupil

•       Iris – muscle/colored portion

•       Pupil – the opening of the iris

Physical Exam Findings:

•       Conjunctival pallor – inside of the lower eyelid appears pale 

•       Corneal reflex – the closing of the eyelid when the cornea is touched (normal finding)

•       Corneal uptake – staining and examining the eye (using Fluorescein) to note increased uptake of the dye; visualization of positive uptake using the Wood’s Lamp/Slit Lamp indicates corneal abrasion/injury and is described as the face on a clock (e.g., 2mm uptake at 3 o’clock position)  

•       EOMI – Extraocular Movements Intact – normal finding

•       Foreign body – clinicians will evaluate for foreign body in the cornea

•       Funduscopic exam – During the eye examination a tool called an ophthalmoscope is used to examine the fundus

The fundoscopic examination is not routinely performed but may be pre-templated in the EMR. Communicate with the clinician as to whether it is appropriate to add/remove from the template.

•       Hyphema – hemorrhage in the anterior chamber of the eye

•       Intraocular pressure (IOP) - the pressure created by the fluids contained in the eye; typically increases with age; abnormally high IOP can cause damage to the eye or glaucoma; tested using a Tonopen

•       Ptosis – drooping of the eyelid 

•       Proptosis – bulging of the eyes 

•       Pupils – clinicians will determine whether the pupils are equal, round, and/or reactive to light o Normal findings:

§  PERRL – Pupils Equal, Round, and Reactive to Light

§  PERRLA – Pupils Equal, Round, and Reactive to Light and Accommodation

§  Accommodation – the ability of the eye to change its focus from distant to near

objects (and vice versa)

o Abnormal findings:

§  Constricted (pinpoint) – abnormal shrinking of the pupil; common in opiate overdose 

§  Dilated – abnormal enlargement of the pupil; common in overdose of antidepressants, Atropine, or stimulants (amphetamines, cocaine, ecstasy)

§  Fixed and dilated – a large pupil that is unresponsive to light; commonly associated with head injury, CVA, and cardiac arrest

 Pupil findings are commonly pre-templated in the EMR. Communicate with the clinician to confirm their findings on examination of the pupils and add/remove from the template as necessary. 

•       Scleral injection (adj. injected) – redness of the sclera (alternative names include conjunctival injection, blood shot eyes, red eyes)

•       Scleral icterus – jaundice/yellowing of the sclera

•       Visual acuities – measure of the resolving power of the eyes, particularly the ability to distinguish letters and numbers at a distance (e.g., Left eye 20/20, Right eye 20/40) 

Common Complaints and Conditions:

•       Cataract – a condition where the lens of the eye becomes clouded/opaque due to tissue breakdown and protein clumping; common in elderly populations; individuals can have surgery to correct this condition

•       Conjunctivitis (pink eye) – inflammation of the conjunctivae 

•       Photophobia – intolerance to light 

•       Glaucoma – a condition of increased pressure within the eye causing gradual loss of sight; common in elderly patients

•       Macular degeneration – progressive disease that destroys the central portion of the retina, impairing vision; common in elderly patients

•       Stye – infection/abscess in the follicle of an eyelash characterized by a tender, red lump near the edge of the eyelid

EARS

Structures (the internal structures of the ear are examined using an otoscope):

•       Internal Structures o External Auditory Canal – tube connecting the outer ear to the tympanic membrane

o   Tympanic Membrane (TM) – the eardrum o Eustachian Tube – maintains balance of air pressure between TM and inner ear

•       External Structures:

o   Helix and Lobe – external portions of the ear made of cartilage

o   Tragus – small projection in front of ear canal

Physical Exam Findings:

•       Canal – edema, exudates (drainage/pus), abrasions, foreign bodies, erythema

•       Cerumen – earwax 

•       Light Reflex (also referred to as cone of light) – normal vs. abnormal light reflex; abnormal light reflex (“dullness”) may be indicative of an ear infection

•       Tympanic Membrane – the clinician looks for bulging, redness (erythema/injection), perforation, deformities, etc.

o Hemotympanum - the presence of blood in the middle ear cavity behind the TM and/or ecchymosis of the TM

•       Hearing devices:

o   Cochlear implant - a small, implanted electronic device that stimulates the cochlear nerve; used to provide a sense of sound to those with severe or profound hearing loss

o   Hearing aid – a small device that fits on or in the ear to amplify sound

Common Complaints and Conditions:

•       Hard of hearing (HOH) – a patient with mild to severe hearing impairment

•       Otitis Externa (OE) – infection or inflammation of the external auditory canal; can have exudate in the external canal and pain on movement of the tragus; layman’s term is “swimmer’s ear”

•       Otitis Media (OM) – middle ear infection commonly seen in children; TM may be bulging and erythematous 

•       Labyrinthitis – a disorder resulting from an infection that inflames the inner ear or the nerves connecting the inner ear to the brain; the inflammation disrupts the transition of sensory information from the ear to the brain; vertigo, dizziness, and difficulties with balance, vision, and hearing may occur

o   Vertigo – an abnormal sensation of motion; the feeling that you’re moving when you’re not; often described as a sensation of feeling dizzy or as if the room is spinning

•       Tinnitus – the sensation of a ringing, roaring, or buzzing sound in the ears or head, often associated with hearing impairment or noise exposure

NOSE

Structures:

•       Nares – the nostrils (singular: naris)

•       Turbinate – structure inside the nose that humidifies and filters air

•       Septum (not pictured) – the cartilage and skin that separates the two nostrils

•       Sinuses – air pockets in the skull to produce mucus that moisturizes the inside

of the nose to protect it from pollutants,

Nares                                                                 micro-organisms, dust, and dirt

o Maxillary – located behind the cheeks o Frontal – located behind the frontal bone and brow ridges

o Sphenoid – located within the nose

Physical Exam Findings:

•       Deviated septum – leaning of the septum to one side or the other of the nose; may create blockage of a nostril

•       Rhinorrhea – discharge from the nose

•       Septal hematoma – a collection of blood in the septum; can occur after nasal trauma; requires emergency surgery 

 For nasal trauma patients, confirm with the clinician if “(-) septal hematoma” should be documented.

Common Complaints and Conditions:

•       Epistaxis – nosebleed o

•       Anterior epistaxis – typically a benign event caused by direct trauma, mucous membranes that have become inflamed, or anticoagulants; often resolves after the application of direct pressure for 15-20 minutes; vasoconstrictive agents, silver nitrate cautery, and/or anterior nasal packing may be used

o Posterior epistaxis – much less common than anterior epistaxis; the hemorrhage is usually from an artery in a posterior location, higher and deeper in the nose; usually drains down the back of the throat but may also bleed out of both nostrils; often the person has another health problem such as high blood pressure, bleeding disorder, or is on anticoagulants; may require an ENT consult or hospitalization

•       Rhinitis – inflammation of the nasal lining which can be caused by infection, allergies, foreign body, etc. 

•       Sinusitis – infection involving one or more of the sinuses

MOUTH AND THROAT

Structures:

•       Lips – external structures providing support to the oral cavity for speech, chewing, and sensation

o   Philtrum – vertical groove between the base of the nose and the border of the upper lip

o   Vermillion border – demarcation between the lip and facial tissue, 

•       Teeth – calcified structures used to break down food

•       Gingiva – gum tissues of the mouth

•       Tongue – fleshy, muscular organ used for tasting, licking, and swallowing

o   Papilla – cone shaped structures on the top of the    tongue that contain taste buds

•       Buccal mucosa – mucous membrane lining the inner cheek

•       Palate – roof of the mouth o Hard – front portion, bony

o   Soft – muscular, behind the hard palate, lacks bone

•       Salivary glands – glands found in the mouth and throat which produce saliva. The major salivary glands are the parotid, submandibular, and sublingual glands

•       Uvula – small structure hanging from the soft palate into the throat; assists with speech; prevents food from entering the nasal cavity 

•       Tonsil – lymphoid tissue located in the back of the mouth

•       Epiglottis – a small flap-like valve of cartilage that closes over the larynx during swallowing so that food goes down the esophagus and not into the lungs

•       Pharynx – throat

•       Larynx – the voice box

Physical Exam Findings:

•       Airway – any part of the air-conducting passages of the respiratory system o

•        Patent – open, no obstruction o Obstructed – blocked  

o Stridor – high-pitched harsh sound heard on inhalation associated with inflammation or narrowing of the larynx or trachea; commonly heard with croup

• Dental  o Avulsion – broken or missing portion of tooth

o     Dental Caries (Cavities) – tooth decay, may cause severe pain o Dentition intact – refers to normal arrangement of teeth

o     Dentures – whether patient has dentures o

o     Edentulous – lacking teeth; toothless

o     Malocclusion – misalignment of teeth in upper and lower jaw, may result in inability to properly close the mouth

Delete “dentition intact” and revise the dental exam if teeth are broken/missing.

•                Drooling – patient is unable to swallow saliva, may indicate airway obstruction

•                Pharynx, Tongue, and Tonsils - clinicians will evaluate for redness, exudates, thrush, ulcers, lesions, etc.

o     Erythema – redness

o     Exudate –pus or clear fluid secreted within the tissues or on the tissue surface o Tongue - clinicians will confirm that the tongue is midline, well-papillated; will evaluate for swelling or any abnormalities 

o     Tonsillar hypertrophy – enlargement of the tonsils, graded on a scale of I-IV  o Thrush - creamy, white patches caused by fungus  o Ulcer - loss of mucosal layer in the mouth

•   Stoma – opening from an organ to the outside of the body (i.e., in tracheostomy)

•   Uvula o Midline – normal position

o   Deviated – leaning to one side, may indicate cranial nerve damage, can also be caused by a tonsillar abscess

o   Uvular edema – swelling of uvula; associated with angioedema, urticaria, and anaphylaxis

Common Complaints and Conditions:

•       Aphonia – complete loss of voice due to disease of voice producing structures

•       Epiglottitis – inflammation of the epiglottis that can result in a life-threatening airway obstruction        

•       Laryngitis – inflammation of the larynx, which can cause a hoarse voice or loss of the voice due to irritation to the vocal folds (vocal cords)

•       Odynophagia – painful swallowing         

•       Pharyngitis – inflammation of the pharynx; referred to as a “sore throat”; common finding with group A streptococcus infection (“strep throat”)

•       Tonsillitis – inflammation of the tonsils

•       Upper Respiratory Infection (URI) – infection (typically viral) of the mouth, nose, throat, larynx, and trachea; referred to as a “cold”

NECK

Structures:

•       Trachea – windpipe, tube passing from larynx to bronchi

•       Lymph nodes – organs within the lymphatic system; important for the proper functioning of the immune system; lymph nodes are located throughout the body, but the largest groupings are in the neck, armpits, and groin

•       Thyroid – endocrine gland in the neck

Physical Exam Findings:

•       Carotid arteries – arteries located in the front of the neck below the angle of the jaw o Pulsations – visualization of the carotid artery pulse

o   Bruit – a sound heard on auscultation due to turbulent blood flow; caused by partial obstruction or narrowing of the artery; a bruit may also be auscultated in the arteries of the heart or abdomen

•       Goiter/thyromegaly – enlarged thyroid

•       Jugular venous distention (JVD) – caused by back-up of fluid in the jugular vein; common in CHF or severe chest trauma 

•       Lymphadenopathy – abnormal size or consistency of the lymph nodes (commonly associated with infection) 

o   Lymphadenitis – swollen/enlarged lymph nodes due to infection o Normal findings on palpation of the lymph nodes: soft, freely mobile o Abnormal findings on palpation of the lymph nodes: hard, fixed, immobile

•       Meningeal Sign (Brudzinski’s) – physically demonstrable symptom of meningitis (described in Neuro section); Patient in supine position with trunk immobilized, upon forced flexion of the neck, elicits a reflex flexion of the hips     

•       Nuchal rigidity – resistance to forward flexion of the neck; stiffness and nuchal rigidity are terms that may indicate possible meningitis

•       Symmetry – noting any potential deformities or abnormalities 

•       Supple – bends and moves easily

•       Tenderness  o Midline tenderness – along the vertebrae; midline tenderness is concerning for a possible vertebrae fracture

o   Paravertebral tenderness – soft tissue

o   Pain on motion

§  Ipsilateral – same side

§  Contralateral – opposite side Common Complaints and Conditions:

•       Hyperthyroidism – overactive thyroid (symptoms may include weight loss, goiter, increased appetite)

•       Hypothyroidism – underactive thyroid (symptoms may include fatigue, depression, weight gain)

•       Torticollis – twisted, stiff neck

CHEST AND RESPIRATORY

                                                                                  Structures:

•                                      Lungs – organs located within the ribcage where air is drawn to oxygenate the blood; the right lung is divided into three lobes. The left lung is divided into two lobes (to accommodate the heart). 

o Abbreviate the lobes as LUL (left upper lobe), LLL (left lower lobe), RUL (right upper lobe), RML (right middle lobe), RLL

(right lower lobe)

•                                      Bronchi – airways of the lungs

•                                      Bronchioles – the final generation of the airways before the alveoli are reached

•                                      Alveoli (not pictured) – thin-walled chambers within the lungs where oxygenation and carbon dioxide exchange take place

•                                      (not pictured) – muscular structure

Auscultation:

•                                      Breath sounds – sounds made by the movement of air through the respiratory system. 

o   Rales (crackles) – a discontinuous sound described as popping, crackling, or bubbling, indicative of fluid or inflammation in the bronchioles and alveoli (common in patients with CHF and pneumonia)

§ Rales can be described as fine or coarse o Rhonchi – a continuous, low-pitched sound indicative of fluid or inflammation in the large airways (common in patients with bronchitis, COPD, and pneumonia)

o   Rub – a discontinuous sound described as a squeaking or grating, indicative of inflamed pleural surfaces rubbing together during respiration (common in patients with pneumonia and pulmonary embolus)

o   Wheezes – a continuous high-pitched whistling sound indicative of air moving through narrowed breathing airways (common in patients with asthma, allergic reactions, and COPD)

o   Crepitus – a crackling or rattling sound caused by gas bubbles pushing through tissue, typically due to trauma

o   Decreased air entry – less air is heard in the lungs than normal

•       Upper airway sounds – abnormal sounds heard when auscultating the lungs that originate from the upper airway (e.g., stridor) 

 Breath sounds may be heard in different parts of the chest (e.g., bilaterally, unilaterally, bibasilar, all fields, right greater than left, individual fields, ½ way up); confirm with the clinician the location of any abnormal breath/lung sounds 

Inspection:

•       Accessory muscle use – the body using accessory muscles in the neck, shoulders, and/or chest to help move air in and out of the lungs during respiratory distress; may be referred to as “abdominal breathing”

•       Retractions – the muscles around the ribcage are pulled in from decreased pressure in the lungs during respiratory distress

 If found on exam, communicate with your clinician to document the location of the retractions: suprasternal, intercostal, intracostal, diaphragmatic, abdominal, etc.

•       Patterns of breathing  o Apnea (adj. apneic) – cessation of breathing

o   Bradypnea – slow breathing, less than 12 breaths per minute in an adult o Dyspnea – shortness of breath/difficult or labored breathing  

o   Orthopnea – shortness of breath that occurs while lying flat, relieved by sitting up; common in Congestive Heart Failure

o   Tachypnea – rapid breathing, greater than 24 breaths per minute in an adult

•       Respiratory rate – breaths per minute

•       Skin Abnormalities  o Access lines - devices placed to give intravenous fluids, blood transfusions, or drugs such as chemotherapy 

§ Central line (central venous catheter) 

§ Implantable port (Port-a-Cath)  o Injuries

o   Operative scars (e.g., sternotomy)

§ Sternotomy - procedure in which a vertical incision is made over the sternum and the sternum is divided to access the heart or lungs; commonly performed for coronary artery bypass grafting (see Heart and Cardiovascular section)

o   Pacemakers, implanted defibrillators (e.g., Automatic implanted cardiac defibrillator (AICD))

•       Symmetry with expansion – both sides of the chest rise and fall equally during normal respiration

Palpation:

•       Subcutaneous emphysema – occurs when air escapes into the tissues covering the chest wall or neck; may appear as smooth bulging of the skin; when palpated the clinician feels crepitus (a crackling sensation); often seen with trauma (stabbings, gunshot wounds, blunt trauma, etc.) and in patients with chest tube placement

Percussion: 

•       Resonance – deep, full, and reverberating sound of the lungs – a normal finding

•       Dullness – sound of the lung produced when fluid or solid tissue replaces air-containing tissues (pneumonia or effusion)

•       Hyperresonance – lower-pitched, hollow sound of the lung typically indicating overinflation (COPD, asthma, or pneumothorax)

•       Tympanic – high-pitched, drum-like lung sounds indicating excessive air in the chest (pneumothorax)

Common Complaints and Conditions:

•       Asthma – a lung disorder in which inflammation causes the airways to swell and narrow; characterized by wheezing, shortness of breath, and chest tightness

•       Atelectasis – collapse of alveoli, visualized on chest x-ray

•       Bronchitis – inflammation or swelling of bronchial tubes (symptoms may include chronic cough productive of yellow/green sputum)

•       Chronic Obstructive Pulmonary Disease (COPD) – lung diseases that are progressive and characterized by difficulty breathing and chronic cough (e.g., emphysema and chronic bronchitis)

•       Coronavirus Disease 2019 (COVID-19) – a contagious respiratory illness caused by a novel coronavirus; symptoms include cough, shortness of breath or difficulty breathing, fever, chills and/or shaking chills, myalgia, headache, sore throat, and/or loss of taste or smell; symptoms can be mild to severe in nature and can progress to pneumonia or respiratory failure

 Ask the clinician for the following and document it in the physician note for any patient with COVID-19 symptoms:

o   The patient’s chief complaints and the qualities of the patient’s symptoms (severity, duration, etc.)

o   Pertinent risk factors (e.g., being 65 years or age or older or having serious underlying medical conditions)

o   Exposure to individuals that tested positive for COVID or have COVID-like symptoms

o   Abnormal vital signs or physical exam findings, such as fever and respiratory findings

o   Whether the patient had a mask on in the ED o If the patient was seen in a COVID-tent area or a regular ED room o What PPE the clinician had on during the patient encounter

o   If admitted – the specific reasons for admission such as respiratory failure or pneumonia 

o   If discharged – a re-evaluation prior to discharge and all follow-up instructions including monitoring symptoms such as temperature and oxygen saturation; when to call their PMD for follow-up; returning to the hospital if symptoms worsen; and CDC guidelines for self-quarantine

•       Croup (laryngotracheobronchitis) – infection of the upper respiratory tract that causes swelling inside the trachea; typically presents with a “barking” cough, stridor, and a hoarse voice; common in children 

•       Hemoptysis – coughing up blood

•       Hypoxia – inadequate oxygen supply to the tissues

•       Infiltrate – an accumulation of a foreign substance (pus, blood, etc.) in the lungs; can be an indication of pneumonia

•       Influenza (Flu) – an acute viral infection of the respiratory tract that can present with fever, cough, sore throat, chills, body aches, and fatigue

•       Intubation – the process of inserting a tube into the airway to keep the patient’s airway open and artificially assist the patient in breathing; used when the patient is in respiratory distress

o   Endotracheal tube (ETT) – breathing tube inserted into the airway via the mouth  o Nasotracheal tube (NTT) - breathing tube inserted into the airway via the nares

•       Nodule – an abnormal growth of tissue, commonly found on chest X-Ray

•       Pleural Effusion – excess fluid between the membranes that line the lungs and the chest cavity

•       Pneumonia – inflammation of the lungs usually due to infection or consolidation caused by cellular exudate in the alveoli

o   Aspiration pneumonia – infection that occurs when food, saliva, liquids, or vomit is inhaled into the lungs 

o   Community acquired pneumonia – pneumonia contracted by a person with minimal exposure to a healthcare facility or hospital 

o   Healthcare acquired pneumonia – pneumonia contracted by a person living within or exposed to a long-term healthcare facility or hospital

•       Obstructive Sleep Apnea – repeated cessation of breathing during sleep

•       Pneumothorax (“Collapsed Lung”) – air or gas in the pleural cavity due to injury of the lung tissue or perforation of the chest wall

o   Spontaneous pneumothorax – occurs without apparent cause or known lung disease o Traumatic pneumothorax – occurs due to an injury (e.g., trauma, surgery, medical complications) 

•       Pulmonary congestion/edema – an abnormal accumulation of fluid in the lungs, common in CHF

•       Pulmonary Embolus (PE) – a blood clot that has traveled to the lungs and obstructed the flow of blood

 Document the patient’s reported history of PE and/or risk factors (see below) for PE within its appropriate place in the physician note (if applicable) 

Risk factors for blood clots, including PE and

DVT

•       Prolonged immobility

•       Travel

•       Recent surgery

•       Fractures

•       History of cancer

•       Birth control pills/estrogen

•       Pregnancy/Recent childbirth

•       Obesity

•       Smoking

•       History of diseases such as CVA, Heart

Disease, or HTN

HEART AND CARDIOVASCULAR

Structures:

•       Atria – upper two chambers of the heart 

•       Ventricle – lower two chambers of the heart

•       Aorta – main artery of the heart pumping oxygenated blood to the circulatory system

•       Pulmonary Artery – artery carrying blood to the lungs for oxygenation 

•       Pulmonary Vein – blood vessel that carries oxygenated blood from the lungs back to the heart

•       Heart Valves – allow blood to flow in one direction through the heart (tricuspid, pulmonary, mitral, aortic)

•       Pericardium (not pictured) – membrane enclosing the

                                                                                         heart

•       Mediastinum (not pictured) – center of the thoracic cavity            which contains the heart and its large vessels, trachea,        esophagus, and other tissues; it extends from the sternum to           the vertebral column and is surrounded by the lungs

Physical Exam Findings for the Heart:

•       Heart Sounds:

o   Normal heart sounds – S1, S2 (lub, dub) in adults

o   Murmur – abnormal heart sound described as a “whooshing” or “swishing” caused by turbulent blood flow in the heart; may indicate valve abnormality

§  Murmurs can be Systolic, Diastolic, or Continuous and are graded on a scale of 1-6 (e.g., 2/6 systolic ejection murmur)

If a patient has history of a murmur or the clinician hears a murmur on examination, ask the clinician for the type and grade of the murmur.

o   Gallop – abnormal heart sound; a ‘third’ sound (S3) heard in addition to the normal heart sounds, common in elderly patients, may indicate CHF or pulmonary edema

o   Rub – scratching, creaking, high-pitched sound from the rubbing of inflamed pericardial layers

o   Other abnormal sounds and abnormal sensations:

§  Clicks – be caused by prosthetic valve

§  Snaps – abnormal valve sound indicating mitral stenosis

§  Thrills – palpated sensation associated with murmurs rated 4/6, 5/6, or 6/6 • Perfusion – the normal oxygenation of the organs and tissues of the body

•       Rhythm:

o   Regular – evenly spaced beats, may vary slightly with inspiration o Regularly Irregular – regular pattern overall with “skipped” beats o Irregularly Irregular – no real pattern, chaotic, very difficult to measure rate accurately

Physical Exam Findings for the Cardiovascular System:

•       Capillary refill – a test of the circulation that is performed by putting pressure on a fingernail quickly and then releasing the pressure. After losing color the nail normally regains its pink color within 2 seconds (if > 2 seconds may indicate dehydration or poor circulation of an extremity)

•       Edema – swelling caused by excess fluid accumulation in the soft tissues; often rated on a scale (1+, 2+, 3+, 4+) and is characterized as pitting or non-pitting edema:

o   Pitting edema – when the affected area is pressed by the clinician, the skin maintains a depression after release of the pressure

o   Non-Pitting edema – when the affected area is pressed by the clinician, the indentation does not persist

If edema is found on physical examination, confirm: the area affected and laterality; the rating of the edema; and whether the edema is pitting or non-pitting (e.g., 3+ pitting edema in the bilateral lower extremities)

o   Angioedema – swelling in the lower layer of skin and mucous membranes typically caused by an allergic reaction or reaction to a drug may occur in the face, tongue, larynx, abdomen, or arms and legs

•       Venous insufficiency (venous stasis) – a decrease in venous function of the extremities which in turn decreases the rate at which blood returns from the extremities to the heart; typically affects the lower extremities; symptoms can include swelling, pain, tightness of the skin, and skin irritation/discoloration

•       Pulses (assessed by palpation or auscultation):

o   Apical – heart (heard by auscultation)

o   Carotid – neck o Femoral – inguinal area

•       Upper extremity pulses:

o   Brachial – upper arm near the bicep o Radial – lateral aspect of the wrist o Ulnar – medial aspect of the wrist

•       Lower extremity pulses:

o   Popliteal – behind the knee o Posterior tibial – posterior border of the medial malleolus o Dorsalis pedis – top of the foot

Pulses are described by clinicians in multiple ways: they can be rated on scale (1+, 2+) or described as intact, absent, strong, etc. As pulses are commonly pre-templated information in EMRs, communicate with the clinician to document the location of the pulse, whether the pulse was symmetric, and their description of the pulse. Remove/add to the template as necessary.

Although edema and pulses are cardiovascular findings, they are often documented in the

Extremities section of the Physical Examination. To avoid documentation variances in a level 5 chart, recognize if there are no musculoskeletal findings documented and ask your clinician what they specifically examined under the musculoskeletal system

Common Complaints and Conditions:

•       Acute Coronary Syndrome (ACS) – a broad term to describe any condition brought on by a reduction of blood flow to the heart (i.e. MI)

•       Aneurysm – a weakening of a vessel wall which causes a widen and bulging of the vessel

•       Arrhythmia – an abnormal heart rhythm

•       Asystole – a form of cardiac arrest in which the heart stops beating and there is no electrical activity present; “flatline”

•       Cardiac Arrest – an abrupt loss of heart function due to a malfunction in the electrical system of the heart; the heart may beat weakly and irregularly or stop completely (asystole); common causes of cardiac arrest are arrhythmias and Myocardial Infarctions

•       Cardiac catheterization – a procedure in which a thin catheter is inserted into an artery and guided into the heart and X-rays of the heart and coronary arteries are taken; evaluates heart function and identifies narrows coronary arteries

•       Cardiac stent – a small wire mesh tube placed in a narrows or blocked artery to improve blood flow

•       Cardiomegaly – enlarged heart

•       Cardiomyopathy – disease of the heart muscle which causes the heart muscle to become enlarged or rigid

•       Congestive Heart Failure (CHF) – condition in which the heart fails to adequately pump blood, results in fluid back-up in blood vessels and the lungs; primary presenting symptom is dyspnea which may be accompanied by orthopnea, edema in the lower extremities, and tachycardia

•       Coronary Artery Disease (CAD) – also referred to as atherosclerotic coronary disease (ASCD); the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries that supply the heart muscle with oxygen and nutrients. It is sometimes also called coronary heart disease (CHD), but although CAD is the most common cause of CHD, it is not the only cause

 Document the patient’s reported history of CAD and/or risk factors for CAD within its appropriate place in the physician note (if applicable) 

Risk factors for CAD: 

•       Prior medical history of diabetes, hypertension,              hypercholesterolemia, hyperlipidemia, obesity            • Family history of myocardial infarction, CAD, or     other heart diseases

•       Social history of smoking, reduced physical

            activity, uncontrolled stress, as dictated by the            clinician

•       Coronary Artery Bypass Grafting (CABG, pronounced “cabbage” or referred to as “open heart surgery”) – surgical procedure in which a blood vessel is taken from another part of the body (typically the inguinal area) and connected to the heart to permit blood to travel around an obstruction in a coronary artery

•       Deep Vein Thrombosis (DVT) – a blood clot which has formed in a blood vessel and caused an obstruction; most common in the lower extremities; symptoms may include pain, swelling, redness 

 Document the patient’s reported history of DVT and/or risk factors for DVT following the HPI (see risk factors on page 48).

•       Hypercholesterolemia – excessive quantity of cholesterol in the blood, a common cardiac risk factor 

•       Hyperlipidemia – excessive quantity of fat (including cholesterol and triglycerides) in the blood

•       Hypertension – high blood pressure 

•       Hypotension – low blood pressure 

•       Infarct – area of injured or dead tissue due to ischemia

•       Ischemia – inadequate supply of blood to an area

•       Myocardial Infarction (MI) – heart attack o ST-Elevation MI (STEMI) – a sudden, complete occlusion of a heart artery, characterized by ST segment elevation on EKG

o   Non-ST-Elevation MI (NSTEMI) – a near-complete or complete blockage of a heart artery without ST segment elevation on EKG, typically diagnosed with Troponin blood markers

•       Occlusion – blockage of a blood vessel due to narrowing of the vessel or a blot clot

•       Palpitations – subjective sensation of the heart fluttering or beating rapidly

•       Premature Atrial Contractions/Premature Ventricular Contractions (PACs/PVCs) – premature, extra heartbeats that disrupt the heart’s rhythm, sometimes causing a sensation of a “skipped” bear or palpitations; normally benign; heart disease, medications, caffeine, tobacco, and anxiety are all common causes of PACs and PVCs

•       Supraventricular Tachycardia (SVT) – any abnormally fast arrhythmia that originates in the atria of the heart; the three main types of SVT are Atrial Fibrillation, Atrial Flutter, and Paroxysmal Supraventricular Tachycardia. 

o   Atrial Fibrillation (A-fib) – an arrhythmia caused by rapid, irregular contractions in the atria of the heart

Patients with Atrial Fibrillation are at a higher risk for thromboembolism and therefore are at risk for stroke, pulmonary embolism, and deep vein thrombosis

o   Atrial Flutter (A-flutter) – an arrhythmia caused by rapid but regular contractions in the atria of the heart

o   Paroxysmal Supraventricular Tachycardia (PSVT) – rapid, irregular contractions in the atria of the heart, characterized by episodes that start and stop abruptly (paroxysmal)

•       Ventricular Arrhythmias – any arrhythmia that originates in the ventricles of the heart; two common types are Ventricular Fibrillation and Ventricular Tachycardia

o   Ventricular Fibrillation (V-fib) – an extremely dangerous arrhythmia caused by rapid, irregular contractions in the ventricles of the heart; often leads to cardiac arrest

o   Ventricular Tachycardia (V- tach) – an arrhythmia caused by rapid but regular contractions in the ventricles of the heart

•       Wolff-Parkinson-White Syndrome – a rare congenital heart disorder in which an extra electrical pathway develops between the atrium and the ventricle, resulting in arrhythmias such as SVT

ADULT & PEDIATRIC VITAL SIGNS REFERENCE SHEET

Abnormal vital signs are indicative of deteriorating health condition. However, some patients may present with abnormal vitals that are considered their baseline (e.g., a COPD patient with a pulse oximetry of 90%, a patient with Hypertension with a blood pressure of 140/80 mmHg). It is important to document a repeat vital sign that is normal following an abnormal vital sign. All repeat vital sign assessments should be documented in the physician note.  

ABDOMEN AND GASTROINTESTINAL (GI)

•       Abdomen – area of the body containing the digestive organs; the abdomen is divided into quadrants and areas:

o   Quadrants: left upper quadrant (LUQ), left lower quadrant (LLQ), right upper quadrant (RUQ), and right lower quadrant (RLQ)

o   Areas: 

§  epigastric (mid-upper abdomen)

                                                                                   _Spleen                   § umbilical (navel/belly button)

§  suprapubic (above the pubic bone) 

§  flanks (side and posterior area just above the hip) 

•       Quadrants/Areas and Associated Organs:

o   Epigastric – stomach o RUQ – gallbladder, liver

o   RLQ – appendix, small intestine, large intestine, ovary in female patients

o   LUQ – spleen, pancreas

^Small o LLQ – small intestine, large intestine, ovary in

                                                                   Intestine           female patients

 o Flanks – kidneys

 o Suprapubic – urinary bladder

Internal Structures of the Abdomen:

•       Liver – important for detoxification of blood, metabolism of drugs, and secretion of bile 

•       Gallbladder – stores bile after secretion by the liver before release to the intestine

•       Stomach – main organ involved in the digestion of food

•       Spleen – produces and removes blood cells, part of the immune system

•       Pancreas – secretes digestive enzymes as well as secretes insulin and glucagon into the blood for management of blood sugar

•       Intestine – digestive tract from the stomach to the anus o Small – long, narrow upper intestine that that absorbs digested nutrients o Large – intestine that reabsorbs water and forms feces

•       Appendix – small appendage near the juncture of the small and large intestine; thought to play a role in the immune system

•       Rectum – final section of the large intestine, terminating at the anus

•       Mesentery – membranous tissue which carries blood vessels and lymph glands, and attaches various organs to the abdominal wall

•       Peritoneum – membrane that lines the wall of the abdomen and covers the abdominal organs

Physical Exam Findings:

Auscultation:

•       Peristalsis – involuntary constriction and relaxation of the muscles of the intestine that push food contents forward in the GI system

•       Bowel sounds – sounds created by the muscular contractions of peristalsis o Normoactive – normal bowel sounds

o   Absent – the bowel sounds are not heard; may be indicative of obstruction o Hyperactive – indicative of increased intestinal activity (common after eating or with diarrhea)

o   Hypoactive – reduction in tone, loudness, or regularity of sounds (common during sleep or with constipation, ileus, or obstruction)

o   Bruits – turbulent blood flow in the aorta or iliac arteries 

Inspection:

•       Distention – outward expansion of the abdomen caused when air or fluid accumulates in the digestive tract or abdomen

•       Hernia – protrusion of an organ or tissue through the wall of the cavity in which it is contained

o   Incarcerated – the hernia is entrapped and cannot be easily returned to its normal location; requires surgical intervention

o   Reducible – the hernia can be returned to its normal location in the abdominal cavity by the clinician pressing on the area

o   Common abdominal hernias include hiatal (upper abdomen), umbilical (umbilicus) femoral (femoral canal in groin), and inguinal (inguinal canal in groin).

•       Mass – an abnormal growth of tissue  o Pulsatile mass – may indicate an abdominal aortic aneurysm (AAA) 

•       Skin Abnormalities:

o   Medical Devices

§  Colostomy – a surgical procedure in which a stoma is created in the abdominal wall and a piece of the large intestine is connected to the surface of the abdomen; a colostomy bag will be attached to the stoma in order to collect waste

§  G-tube (gastrostomy tube) - a tube inserted through the abdominal wall to deliver nutrition, fluids, and/or medication directly into the stomach

•       PEG tube (percutaneous endoscopic gastrostomy tube) – a type of G-tube placed by endoscopy

§  Insulin Pump – small, battery-operated device that delivers insulin to diabetics

§  J tube (jejunostomy tube) –a tube inserted into the jejunum (midsection of small intestine) to deliver nutrition, fluids, and/or medication

§  Nasogastric/Orogastric tube (NGT/OGT) – a small tube placed either through the nose or mouth into the stomach to deliver nutrition, fluids, and/or medication directly into the stomach; typically placed in the ED

o   Operative scars – due to prior procedures such as appendectomy, cholecystectomy, C-section, etc. 

§  Appendectomy – surgical removal of the appendix

§  Cholecystectomy – surgical removal of the gallbladder

§  C-Section (Cesarean) – surgical delivery of a baby by an incision in the abdomen

o   Rashes – see Integumentary (Skin) section

Percussion:

•       Ascites – fluid in the peritoneal cavity of the abdomen

•       Tympany – high-pitched, drum-like sounds; normal finding in the abdomen

•       Dullness – dulled sound produced over the liver (a normal finding) or due to ascites

•       Organomegaly - abnormal enlargement of organs o Hepatomegaly – enlarged liver

o   Splenomegaly – enlarged spleen

Palpation (light or deep):

•       Soft abdomen – normal finding

•       Rigid abdomen – involuntary stiffness and tightness of the abdominal muscles (may indicate internal bleeding or enlargement of organs)

•       Common indications of abdominal tenderness: 

o   Rebound Tenderness – upon deep palpation, pain increases after palpation is released (may indicate peritoneal irritation)

o   Guarding (voluntary) –abdominal muscle spasm which occurs when an examiner palpates inflamed areas or organs in the abdomen

o   Guarding (involuntary) – involuntary abdominal muscle spasm which cannot be suppressed; occurs even in the absence of palpation (may indicate peritoneal irritation)

•       Murphy’s Sign – increased pain and associated splinting of respiration (“catching their breath”) when the RUQ is palpated during deep inspiration (common indicprator of cholecystitis) 

•       McBurney’s Point – located in the right lower quadrant; tenderness at McBurney’s point

(McBurney’s sign) is a common indicator of appendicitis

•       Obturator Sign – the right leg of patient is raised with knee flexed, leg is then rotated internally at the hip; positive if motion causes or increases abdominal pain (common indicator of appendicitis)

•       Psoas Sign –the patient lies on their back or left side and is asked to flex the right hip against resistance; positive if motion causes or increases abdominal pain (common indicator of appendicitis)

•       Rovsing’s Sign – pain felt in the right lower quadrant when the left lower quadrant is palpated (common indicator of appendicitis)

•       Rectal examination –the clinician palpates for external or internal bleeding, masses, and tenderness of the rectum; typically, the rectal examination is documented below the abdominal examination in the physician note

 If indicated, the clinician may also perform a hemoccult (guaiac) test during the rectal examination to detect occult blood in the stool. This is documented within the rectal examination.

If a clinician performs a rectal (or genitourinary) exam, they will most likely have a chaperone present. CIMs are not authorized to be chaperones; if you are asked to chaperone an exam, politely decline and locate a team member that can chaperone the exam (RN, PCT, another ED clinician, etc.). Document the title and name of the team member who was the chaperone in the physical exam.

Example of Rectal Exam:  

RECTAL: (-) mass, (-) tenderness. Stool brown, Hemoccult (-) with Performance Monitor as control. A female RN chaperone, T. Nowak, was present with me during the entire rectal examination.

Common Complaints and Conditions:

•       Abdominal Aortic Aneurysm (AAA, “triple A”) – condition in which the wall of the abdominal aorta becomes weak and bulges; a rupture of the aneurysm can be lifethreatening

•       Cholecystitis – inflammation of the gallbladder

•       Cholelithiasis – gallstones; pieces of solid material that form hard, crystal-like particles in the gallbladder

•       Cirrhosis – a progressive disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from functioning properly

•       Colitis – inflammation of the large intestine

•       Crohn's disease – a chronic inflammatory bowel disease that causes inflammation of the digestive tract; typically affects the small intestine but can affect the esophagus, large intestine, etc.

•       Diverticulosis – when pockets (diverticula) form in the inner lining of the intestines; common in older adults

•       Diverticulitis – inflammation or infection of the diverticula formed in diverticulosis; may require antibiotic treatment or surgery 

•       Dyspepsia – indigestion; nonspecific discomfort within the upper abdomen which can include pain, bloating, nausea, belching, etc.

•       Emesis – vomiting o Hematemesis – vomiting blood

•       Gastritis – inflammation of the stomach lining (e.g., infection, alcohol)

•       Gastroenteritis – inflammation of the gastrointestinal tract associated with nausea, vomiting, and diarrhea

•       Gastroesophageal reflux disease (GERD) – a condition in which acid from the stomach travels back up into the esophagus, causing a burning sensation (heartburn)

•       Gastrointestinal Fistula – abnormal opening in the stomach or intestines which allows the contents to leak. 

•       Hematochezia – bright red blood per rectum, indicates bleeding in lower GI tract

•       Hemorrhoids – swollen blood vessels that line the anal opening, typically caused by constipation

•       Hepatitis – inflammation of the liver

•       Incontinence (bowel) – loss of bowel control

•       Ileus – inability of the bowel to contract normally and move waste out of the body; can lead to an obstruction

•       Jaundice – a condition in which the skin and eyes turn yellow because of increased levels of bilirubin in the blood

•       Melena (adj. melanotic) – black, tarry stool indicative of bleeding from the upper GI tract 

•       Pancreatitis – a inflammation of the pancreas

•       Peptic Ulcer Disease (PUD) – a disorder in which ulcers form on the lining of the stomach or the first part of the small intestine (duodenum)

•       Peritonitis – inflammation of the peritoneum requires antibiotic treatment and surgery; c causes are pelvic inflammatory disease in women, surgery, perforation of an infected abdominal organ, peritoneal dialysis, or ascites.        

ENDOCRINE

The Endocrine system is composed of glands that both produce and secrete hormones. These glands include the hypothalamus, pituitary, thyroid and parathyroid, adrenal glands, pancreas, ovaries, and testes.

Common Complaints and Conditions:

•       Hyperglycemia – high blood sugar

•       Hypoglycemia – low blood sugar

•       Oliguria – decreased urination

•       Polydipsia – excessive thirst

•       Polyphagia – excessive hunger

•       Polyuria – excessive urination

•       Diabetes Insipidus – a disease caused by deficiency of antidiuretic hormone (ADH) or lack of response to ADH; symptoms include polydipsia and polyuria.

•       Diabetes Mellitus (DM) – a disease marked by high levels of glucose in the blood o Type I DM (Insulin Dependent Diabetes Mellitus or IDDM) – the pancreas produces little to no insulin; it can be inherited and is typically diagnosed in childhood/young adults; daily injections of insulin are needed

o Type II DM (Non-Insulin Dependent Diabetes or NIDDM) – the pancreas

produces insulin but is unable to use the insulin to control the blood sugar (insulin resistance); more common than Type I and typically occurs in adulthood; Type II Diabetics may need injections of insulin; however, some Type II Diabetics require only oral medication treatment. o Common symptoms of DM include polydipsia, polyuria, and polyphagia 

Diabetes Insipidus and Diabetes Mellitus are caused by different mechanisms and are unrelated to each other

•       Diabetic Ketoacidosis (DKA) – an acute, life-threatening complication of DM when insufficient insulin levels in the body prevent the breakdown of glucose, which results in the liver producing ketones as a fuel source; the increase in ketones causes the blood to become acidic; symptoms may include malaise, nausea, vomiting, dehydration, and confusion. 

•       Diabetic Neuropathy – a complication of DM where persistent hyperglycemia causes nerve damage resulting in pain, numbness, and/or loss of muscle tone. Diabetic neuropathy typically presents in the legs and feet.

Individuals with Diabetic Neuropathy can present with severe cellulitis or wounds to the lower extremities from compromised blood supply or from failure to feel when they sustain a cut, abrasion, etc. to the area

GENITOURINARY (GU)

Genitourinary Structures:

•       Kidneys – organs that maintain chemical and electrolyte levels in the body by filtering the blood and excreting waste products as urine; also secretes hormones

•       Ureter – tube that passes urine from the kidney to the urinary bladder

•       Urinary bladder – stores urine until it is excreted from the body

•       Urethra – tube carrying urine from the urinary bladder outside the body, also carrying semen outside the body in males

•       Perineum – area between the anus and either the scrotum or vulva

•       Anus – opening at the end of the rectum, carrying solid waste          outside the body

Male Genital Structures:

•       Penis – male genital organ

•       Foreskin – retractable fold of skin covering the end of the penis

•       Glans – rounded part forming the head of the penis

•       Scrotum – suspended sack of skin holding the testicles

•       Testicle (pl. testes) – oval organ located in the scrotum that produces sperm

•       Spermatic Cord – cord that suspends the testicles within the scrotum and contains the vas deferens, blood vessels, lymph vessels, nerves and connective tissue linking the testicles to the abdominal cavity

•       Prostate – muscular, walnut-sized gland that surrounds part of the urethra and secretes seminal fluid, a milky substance that combines with sperm to form semen

Female Genital Structures:

•       Vulva – external structures of the female reproductive tract o Labia – the folds of skin at either side of the vagina o Clitoris – small, sensitive erectile tissue at the anterior end of the vulva o Bartholin’s Gland – a pair of glands near the entrance of the vagina which secrete fluid that lubricates the vulva

•       Vagina – muscular tube leading from the external genitals to the cervix of the uterus

•       Uterus – hollow, pear-shaped organ located in the lower abdomen that expands during pregnancy to hold the growing fetus and contracts during labor to deliver the child o Endometrium – inner layer of the uterus which thickens in preparation to receive a fertilized egg and disintegrates and is expelled through the vagina when pregnancy has not occurred (process known as the menstrual cycle)

o Cervix – narrow, neck-like passage at the lower end of the uterus

§ Cervical Os – opening at the end of the cervix  o Fundus – top portion of the uterus, opposite of the cervix

•       Adnexal Structures o Fallopian Tube – passageway that allows for eggs to travel from ovaries to the uterus

o Ovary – reproductive organ in which ova (eggs) are produced

•       In Pregnancy o Amniotic Sac – fluid sac where fetus develops within the uterus o Umbilical Cord – flexible structure which connects the fetus to the placenta and delivers oxygenated, nutrient-rich blood 

o Placenta – flat, circular organ providing nourishment for the fetus during development 

Physical Exam Findings:

•       Costovertebral angle (CVA) tenderness – pain produced when firmly tapping over the kidneys; common indicator of renal inflammation or disease; often documented in the abdominal section of the physical examination

Patients with kidney stones most commonly complain of flank pain, with flank tenderness or CVA tenderness on exam. If a patient has CVA tenderness, confirm whether the tenderness is unilateral (right, left) or bilateral. 

•       Nephrostomy tube – a tube inserted from the flank into the kidney to drain urine

•       Rectal exam - Internal examination of the rectum focuses on rectal wall tone, and masses, and (if male) prostate gland

o   Abnormal findings of the prostate include hardness/firmness, nodular areas, or enlargement

•       Skin Abnormalities – redness, swelling, skin lesions, pustules, discharge, masses, etc.

•       Male Physical Exam Findings:

o   Penis, Foreskin, Glans

§  Circumcision Status – circumcised (foreskin surgically retracted) vs.

uncircumcised

o   Testicles  

§  Cremasteric Reflex – a reflex drawing up of the scrotum and testicle in response to touching the superior and medial aspect of the thigh; diminished or absent on the side of a testicular torsion

§  Descended – normal physical exam finding

§  Undescended – a testicle remains within the abdominal cavity, abnormal finding § Varicocele – enlargement of veins within the scrotum

•       Female Physical Exam Findings:

o   Breast exam - typically documented as a separate exam below Chest and Respiratory 

§  Abnormal findings include tenderness, skin abnormalities, asymmetry, nipple discharge and/or retraction, lymphadenopathy, masses, and peau d’orange

•       Peau d’ orange – dimpling of the skin of the breast

o   Internal exam – commonly referred to as a bimanual exam o Cervix – mobility, tenderness, pain on cervical motion

§  Cervical motion tenderness (CMT) may be indicative of pelvic inflammatory disease (PID) 

o   Cervical os – normally closed until the first stage of labor

o   Vaginal walls – abnormal findings include lesions or discharge o Uterus

§  Tilting – anteverted (toward the bladder), retroverted (toward the spine) § Enlargement – may be indicative of uterine fibroids or pregnancy

§  Adnexa – abnormal findings include tenderness, enlargement, rigidity. 

If a genitalia or rectal examination is performed, a chaperone will likely be present. Document the title and name of the ED member who was the chaperone in the physical exam. As a reminder, CIMs are not authorized to chaperone an examination. 

Common General Complaints and Conditions:

•       Anuria – no urine output

•       Diuresis – increased or excess production of urine; can be induced (to treat high blood pressure, fluid retention, and kidney disease) using a diuretic 

o   Diuretic – drug that increases urine production by increasing the amount of salt and water expelled in urine 

•       Dysuria – painful urination

•       Hematuria – blood in the urine

•       Hydronephrosis – distention of the kidneys due to buildup of urine, commonly due to a blockage from a kidney stone

•       Hyperkalemia – high potassium level in the blood

•       Hypokalemia – low potassium level in the blood

•       Incontinence (urine) – loss of urine control

•       Metabolic acidosis – condition in which the body’s blood pH becomes too acidic; often occurs from overproduction of acid, excessive loss of bicarbonate (a base), or when the kidneys do not filter enough acid from the blood

•       Nephrectomy – surgical removal of a kidney

•       Nephrolithiasis/Renal Calculi (kidney stones) – crystalized mineral deposits formed in the kidney or urinary tract 

•       Nocturia – excessive urination at night

•       Oliguria – decreased urination

•       Polyuria – excessive urination; diuresis (excessive urine production) can lead to polyuria

•       Pyelonephritis – inflammation of the kidney usually due to an infection that has ascended from the urinary bladder; symptoms may include fever, flank pain, urinary symptoms 

•       Renal colic – abdominal/flank pain caused by kidney stones

•       Types of Renal Disease/Loss of Function:

o   Acute Kidney Injury (AKI) – may also be referred to as “acute renal insufficiency”; abrupt decline in kidney function characterized by acute decrease of GRF levels and increase of serum creatinine levels; if AKI cannot be reversed, or occurs frequently, it can lead to Chronic Kidney Disease

o   Chronic Kidney Disease (CKD; Renal Failure) – the slow, gradual loss of kidney function; rated on scale of 1-5, with 5 (End Stage Renal Disease) being the most severe; CKD leads to kidney damage, accumulation of waste products in the blood, and electrolyte imbalances

§ End Stage Renal Disease (ESRD) – the most severe form of CKD (only 10-15% of kidney function) which requires dialysis or kidney transplant

•       Arteriovenous (AV) fistula – abnormal connection between an artery and a vein; can be surgically created for dialysis patients for hemodialysis procedures

•       Hemodialysis – a machine uses a man-made filter to remove excess fluid and waste products from the blood and corrects electrolyte imbalances

•       Peritoneal dialysis (PD) – a treatment that uses the peritoneum and a cleaning solution called dialysate to clean the blood; dialysate absorbs waste and fluid from the blood, using the peritoneum as a filter. 

•       Urinary Tract Infection (UTI) – an infection in any part of the urinary system (kidney, ureter, bladder, or urethra); common in women and the elderly; symptoms may include dysuria, frequent urination, suprapubic discomfort and feeling the need to urinate despite having an empty bladder (urinary frequency)

•       Sexually Transmitted Infection (STI) – infections that are transmitted during sexual contact (vaginal, anal, and/or oral sex); also known as Sexually Transmitted Diseases

(STDs)

o Gonorrhea and Chlamydia (G/C) – the two most common STIs, which are caused by bacterial infections; symptoms may include discharge, itching/burning, abdominal pain, etc. 

If a patient presents with Gonorrhea or Chlamydia symptoms, the clinician will likely send a Gonorrhea and Chlamydia culture for analysis. Review documentation requirements for cultures in the Diagnostics section of the manual.

Common Complaints and Conditions in Males:

•       Benign Prostatic Hyperplasia (BPH) – noncancerous enlargement of the prostate gland which in some cases can cause partial or complete obstruction of the urinary tract

•       Epididymitis – inflammation of the epididymis

•       Hydrocele – fluid filled mass in the scrotum

•       Priapism – persistent, painful erection (rigid state of the penis, typically during sexual excitement)

•       Testicular Torsion – twisting of the spermatic cord which requires emergency surgery to repair blood flow to the testicle 

Common Complaints and Conditions in Females:

•       Abortion (AB) – involuntary or voluntary termination of a fetus prior to viability o Spontaneous abortion (miscarriage) – involuntary termination o Induced abortion – voluntary termination

•       Bartholin’s (Duct) Cyst – a fluid-filled swelling in the Bartholin’s Gland which occurs when the duct of the gland becomes blocked

•       Dysfunctional Uterine Bleeding (DUB) – abnormal vaginal bleeding due to changes in hormone levels

•       Dysmenorrhea – painful menses

•       Ectopic pregnancy – fertilized ovum that is developing outside the uterus which requires emergency surgery

•       Endometriosis – a condition where the endometrium grows on other organs in the pelvis abdominal cavity, usually the ovaries, fallopian tubes, and uterine ligaments; leads to inflammation and scarring of these structures and causes pelvic pain

•       Menopause – permanent cessation of menstruation

•       Ovarian Cyst – fluid-filled sacs within or on the surface of an ovary

•       Ovarian Torsion – rotation of the ovary to the point that blood flow is occluded requiring emergency surgery

•       Pelvic Inflammatory Disease (PID) – inflammation or infection of the uterus, fallopian tubes, and adjacent pelvic structures, often caused by an untreated STI; common cause of lower abdominal or pelvic pain 

Additional Terms:

•       Beta Human Chorionic Gonadotropin (BHCG) – serum test for pregnancy (discussed in the Diagnostics section)

•       Dilatation & Curettage (D&C) – the dilation of the cervix and curettage (scraping) of the endometrium to remove tissue in the uterus (e.g., after an abortion or to treat fibroids, polyps, etc.)

•       Gravida (G)/Para (P)/Abortion (A) – shorthand for a woman’s obstetric history  o Gravida – total number of pregnancies o Para – number of viable births

o Abortion – unsuccessful pregnancies 

For Example: A woman has had 2 full-term births, 1 premature birth, and 1 abortion/miscarriage would be documented as G4P3A1.

•       TPAL: More in-depth documentation of a woman’s obstetric history regarding the total number of births. When dictating the TPAL system, clinicians may only dictate TPAL, or also include Gravida (GTPAL) o T – full-term pregnancies o P – pre-term births (prior to 37 weeks gestation) o A – abortions or miscarriages o L – live births

For Example: A woman has had 2 full-term births, 1 premature birth, and 1 abortion/miscarriage would be documented as 2-1-1-3 (TPAL) or G4 T2 P1 A1 L3. (GTPAL)  MUSCULOSKELETAL AND EXTREMITIES

Structures:

•       Bone – hard, calcified tissue creating the skeleton

•       Ligament – fibrous connective tissue that connects bones together

•       Muscle – fibrous tissue with the ability to contract and move parts of the body

•       Tendon – a flexible, but inelastic cord that connects muscle to bone

•       Cartilage – flexible material found in joints to prevent bones from rubbing against one another

                                                                                                 Upper Extremity:

•       Clavicle – collarbone, links the shoulder and

                                                                                                       sternum

•       Scapula (not pictured) – shoulder blade

•       Humerus – upper arm bone

•       Radius – lateral forearm bone

•       Ulna – medial forearm bone

•       Carpals – wrist bones

•       Metacarpals – hand bones

•       Metacarpophalangeal joints (MCP) – points of attachment of the fingers

•       Phalanges – finger bones

•       Interphalangeal joints (IP) – joints in the

fingers; proximal (PIP); distal (DIP)

Spine/Vertebrae:

•       Cervical (C-Spine) – 7 neck vertebrae 

•       Thoracic (T-Spine) – 12 thorax vertebrae, ribs are attached 

•       Lumbar (L-Spine) – 5 lower back vertebrae

•       LS Spine – the area including the lumbar and sacral portions of the spine

•       Sacrum – fused vertebrae between the hipbones

o Coccyx – small triangular bone formed of fused vertebrae at the base of the spine

Thoracic Cage:

•       Sternum – breastbone

•       Xyphoid Process – lowest portion of the

                                                                                                      sternum

•       Ribs – 12 paired bones on either side of the

                                                                                                      sternum

Lower Extremity:

•       Femur – upper leg bone

•       Patella – kneecap

•       Tibia – medial lower leg bone

 o Medial malleolus – bony process at the distal end of

 the tibia

•       Fibula – lateral lower leg bone

 o Lateral malleolus – bony process at the distal end of

 the fibula

•       Tarsals – ankle bones

•       Metatarsals – foot bones

•       Metatarsophalangeal joints (MTP) – points of

 attachment of the toes

•       Phalanges – toes

Physical Exam Findings:

•       Atrophy – wasting, a decrease in size of an organ or tissue 

•       Crepitus – crackling /grating sound that indicates bone rubbing directly on bone 

•       Deconditioning – the loss of muscle tone and endurance due to chronic disease, immobility, or loss of function

•       Deformity – deviation from the normal structure, shape, size, or alignment; may indicate fracture, dislocation, amputation, or other abnormality

Communicate with your clinician to document any deformities present on examination (e.g., above knee amputation (AKA), below knee amputation (BKA)) and confirm there are no discrepancies in the physician note.

•       Motor Function: o Muscle Tone – level of passive muscle contraction when at rest

§  Decreased (flaccid) 

§  Increased (rigid/spastic)

•       Range of motion (ROM) – the movement potential (flexion, extension, rotation) of a joint 

o Active ROM – patient moves extremity without assistance o Passive ROM – clinician manually moves the extremity o Full ROM – normal, patient able to move extremities without limitation o Limited ROM – reduction in the normal range of motion o Clinicians will also assess if the patient has pain on ROM

•       Spine Abnormalities o Kyphosis – posterior curvature of the spine, result of disease or congenital problem

o Scoliosis – congenital lateral curve of the spine

•       Straight Leg Raise (SLR) – tests for sciatica or herniated disc in the lumbar spine; patient is placed in a supine position and the clinician raises the patient’s leg by flexing the hip; if patient experiences pain during the movement, it is considered a positive SLR;

the angle at which the pain is elicited is documented in the physician note For Example: Straight Leg Raise (+) at 30 degrees in left leg.

•       Tenderness o Bony tenderness – pain elicited by pressing on a bone in the spine o Midline tenderness – tenderness in the median line of a joint or other body part; often used to describe tenderness (or lack thereof) on palpation down the spine

o Paravertebral tenderness – pain elicited by pressing on soft tissue surrounding the spine; also referred to by its location in the spine (e.g., paracervical tenderness, parathoracic tenderness, paralumbar tenderness) 

When a clinician dictates any findings in or around the spine, ask the clinician if they want to specify the location, e.g., “bony tenderness at C5”

•       Varicose Veins – enlarged, twisted veins visible under the skin (common in the legs) 

Common Complaints and Conditions:

•       Arthralgia – joint pain due to injury or illness

•       Arthritis – joint pain, stiffness, and swelling o Gout – form of arthritis due to a buildup of ureic acid; typically, only affects one joint during an episode; symptoms include pain, erythema, stiffness, and/or swelling of the joint

o   Osteoarthritis – form of arthritis due to the breakdown of cartilage in the joints; often affects the hands, spine, knees, and hips

o   Rheumatoid Arthritis – an autoimmune disease characterized by chronic inflammation of the joints

•       Herniated disc – condition where the intervertebral disc protrudes from the spinal column; each disc is named using the 2 vertebrae it is between (e.g., L4-L5 disc)

•       Myalgia – muscle pain 

•       Orthopedic Injuries o Dislocation – displacement of the end of a bone from a joint

§ Reduction – procedure to repair a fracture or dislocation to proper alignment  o Fracture – break of bone

o   Sprain – stretching or tearing of a ligament o Strain – overstretching or tear of a muscle and/or tendon

Fractures, Reductions, and Fracture Care are often documented incorrectly. Review these documentation requirements in the Procedures section of the manual so that this information is documented correctly in the physician note.

Documentation of fractures must include: 

•       Specific site

•       Laterality

•       Open or Closed

•       Displaced or Nondisplaced

•       Type of fracture (transverse, oblique, spiral, comminuted, segmental, greenstick)

•       Osteomyelitis – infection of the bone

•       Radiculopathy – injury to the root of a nerve causing pain, numbness, tingling, or weakness; commonly referred to as a “pinched nerve”

•       Sciatica – lower back pain localized to the sciatic nerve (nerve located in L4-S2); pain can radiate down one or both legs

For back pain, document specific findings such as the type of injury, non-traumatic findings, and region with laterality (when applicable)

NEURO AND PSYCH

In contrast to other parts of the exam where inspection or palpation are key, the neurologic exam relies on deductive skills and specific maneuvers to determine whether the nervous system is impaired.

 Neurological exams are commonly pre-templated in the EMR, but they may have findings that the clinician did not perform. Conversely, there may be examination findings that were performed by the clinician but are not included in the template. Communicate closely with the clinician to determine the information that must be removed or added to the neurological exam correctly.

Physical Exam Findings:

•       If not documented in the Generalized Appearance, the clinician may include the patient’s affect, alertness, mood, and/or orientation in the Neuro/Psych section of the physical exam.

•       Coordination and Gait o Ataxia (adj. ataxic) – defective muscular coordination 

o   Gait – pattern of walking; patient may be asked to walk heel-to-toe in a straight line; walk across the room, turn, and come back; rise from a sitting position, etc. o Point-to-Point Movements – used to test voluntary motor function

§  Finger-to-nose – patient touches examiner’s index finger and their nose alternately several times, while examiner moves their finger; tests for the ability to control the hand with precision

§  Heel-to-shin – with the patient lying supine, the examiner instructs them to place the heel of their foot on the opposite shin just below the knee (i.e. right heel on left shin) and then slide it down their shin to the top of their foot

o   Pronator Drift – patient is asked to hold both arms fully extended at shoulder level in front of them, with palms upwards, and hold the position; positive test when the patient is unable to maintain the position in one of the limbs (common in stroke patients)

o   Romberg Test – positive when patient unable to maintain balance while standing with eyes closed and feet together

•       Cranial Nerves (CNs) – CNs II-XII are generally tested throughout the physical exam; CN I (sense of smell) is not commonly tested.

•       Eyes

o   Pupils – described in Eye section. PERRL or PERRLA is normal; clinicians will look for abnormalities such as asymmetry and fixed or dilated pupils. 

o   Nystagmus – repetitive, involuntary eye movement; can be horizontal, vertical, or circular movements

o   Gaze preference – inability to produce eye movements to the right or left side, i.e. a patient with right gaze preference cannot produce eye movements to the left side (common in stroke patients)

•       Facial drooping – unilateral sagging of the face; clinicians will look for flattening of wrinkle lines on forehead, drooping of eyebrows, and drooping of the corner of the mouth

(common in stroke patients and patients with Bell’s Palsy)

•       Dysarthria – defect in the muscular control of speech, causing slowed or slurred speech 

•       Meningeal Sign (Kernig’s Sign) – the patient is in the supine position, the clinician flexes the hip and knee, and then while holding the hip immobilized, the knee is extended; is positive if there is resistance to knee extension or pain on extension 

•       Mental Status as Above - refers to the description of the patient’s mental status described in general survey/generalized appearance.

•       Motor Function:

o   Hemiparesis – unilateral paralysis/weakness (common finding in stroke)  o Focal neurological deficit – impairment of the nerve, spinal cord, or brain function that affects a specific region of the body (e.g., weakness of the arm) 

•       Reflexes: o Deep Tendon Reflexes (DTR) – graded on a scale of 0-5+; 2+ is normal o Babinski’s Reflex (Plantar Reflex) – the clinician strokes the lateral aspect of the sole of the foot and observes whether all toes flex downward (negative Babinski’s reflex) or if the great toe extends (dorsiflexion) and the other toes fan outward

(positive Babinski’s reflex)

§  A negative Babinski’s Reflex is normal in adults and children over 2 years old

§  A positive Babinski’s Reflex is normal in children less than 2 years old

 Reflexes are not performed often but are included in many EMR templates. 

•       Sensory Function – Includes testing for touch sensation, pain sensation, proprioception (sense of position), stereognosis (object recognition), vibration, and discrimination

•       Strength:

o   Extremity strength – assessed by having the patient push and pull against resistance; rated on a scale of 0-5, with 5 being normal strength; a normal finding is 5/5 strength in all extremities

o   Grip strength – assessed by having the patient grip an object with their hand; rated on the same scale as above 

•       Structures of the mouth – clinicians will evaluate if structures such as the uvula and tongue are midline (normal) or deviated to the right or left (indicates possible stroke or brain injury)

 The National Institute of Health Stroke Scale (NIHSS) is a scale that assesses the severity of a patient’s stroke symptoms; the clinician will use some of the above tests to evaluate the patient’s level of consciousness, visual function, motor function, sensation, cerebellar function, and language; a NIHSS scale and score must be documented for every patient that presents to an ED with stroke-like symptoms.

Common Neuro/Psych Complaints and Conditions:

•       Amnesia – loss of memory due to brain damage, disease, or trauma

•       Anxiety disorder – disorder manifested by persistent, excess worry and fear that interferes with daily activities

•       Aphasia – impairment in ability to communicate through speech, writing, or sign due to brain dysfunction  

•       Attention-Deficit/Hyperactivity Disorder (ADHD) – a disorder associated with chronic pattern of inattention, hyperactivity, and/or impulsivity

•       Autism Spectrum Disorder (ASD) – a range of neurodevelopmental disorders typically diagnosed in early childhood which commonly affect communication and behavior 

•       Bell’s Palsy – a condition that causes temporary facial paralysis, typically unilateral, due to inflammation or compression of the facial nerves

•       Bipolar disorder – disorder associated with periods of abnormal shifts in mood, energy, and activity levels; individuals have periods of elation and high energy (manic episodes) and periods of depression and indifference (depressive episodes) 

•       Cerebrovascular Accident (CVA) – also referred to as a stroke; condition in which a blockage or rupture of vessels in the brain causes cell death from reduced blood flow; symptoms depend on the area of the brain affected but can include unilateral loss of strength and/or sensation, difficulty comprehending and/or producing speech, difficulty with balance, or loss of vision

•       Transient Ischemic Attack (TIA) – a condition in which temporary blockage of vessels in the brain causes reduced blood flow, leading to brief neurological dysfunction; TIA presents with symptoms of a stroke, but symptoms resolve spontaneously

•       Coma – state of deep unconsciousness where the individual cannot voluntarily respond to their environment

•       Depression (Major Depressive Disorder) – disorder characterized by persistently feeling of sadness or apathy, loss of interest in activities, decreased energy, etc. which causes significant impairment in daily life

•       Dyskinesia – involuntary movement of the tongue, lips, face, trunk, and extremities • Dysphagia – difficulty swallowing

•       Dysphasia – difficulty with speech

•       Meningitis – inflammation of the meninges, typically caused by an infection. Symptoms often include headache, fever, and stiff neck. 

•       Overdose – an excessive and dangerous dose of a substance; typically associated with alcohol and recreational drugs but can also apply to other substances and medications such as Aspirin, Tylenol, Beta-blockers, etc.

•       Paresthesia – a subjective sensation experienced as numbness, tingling, or “pins and needles” which typically occur in the extremities; caused by abnormalities in the sensory pathways such as nerve damage

•       Seizure - the physical symptoms or changes in behavior associated with an episode of abnormal electrical activity in the brain

o Epilepsy - a disorder in which the individual has recurrent seizures o Common Types of Seizures:

§  Tonic-Clonic (Grand Mal) – seizure characterized by loss of consciousness and tonic (stiffening)-clonic (twitching/jerking) activity; individuals may also have urinary/fecal incontinence, drooling, biting of the tongue, etc.

§  Febrile – seizure caused by a rapid spike in fever; these seizures are general

tonic-clonic in nature; common in infants and children

§  Absent (Petit Mal) – seizure characterized by abrupt, short-term lack of conscious activity (“staring into space”); individuals will stop moving, speaking, and will not respond to questions, but will have full recovery after the seizure ends; common in children 

Confirm all associated symptoms of seizure such as urinary/fecal incontinence with the clinician and document them in the physician note

•       Substance use disorder (addiction, substance abuse) – compulsive use of a substance despite harmful consequences, often with physical and/or psychological reliance; these substances can include alcohol, nicotine, and both prescriptive and non-prescriptive drugs such as opioids and amphetamines

•       Schizophrenia – disorder characterized by distortions in sense of self, perception, thinking, emotions, and language; common symptoms include hallucinations, delusions, flat affect, and social withdrawal   o Hallucination – perception of an object or event in the absence of a stimulus (i.e. hearing voices)

o Delusion – a strongly held belief despite evidence that the belief is false (i.e. believing that they are a superhero or believing an organization is “out to get them”) 

•       Suicidal ideation (suicidal thoughts) – thoughts of committing suicide which may or may not include a plan

•       Syncope – partial or complete loss of consciousness (to pass out, to faint)

•       Withdrawal – physical and mental symptoms that occur after stopping or reducing intake of a substance that can produce physical dependence (alcohol, opioids, etc.) o Delirium Tremens (DTs) – a form of severe alcohol withdrawal associated with chronic alcohol abuse, which presents with mental and/or nervous system changes such as confusion, agitation, hallucinations, body tremors, diaphoresis, nausea, and vomiting

HEMATOLOGIC/IMMUNOLOGIC

The Hematologic system does not have a specific exam. It is evaluated using diagnostic testing.

Common Complaints and Conditions:

•       Anemia – blood disorder in which there is a reduction in the amount of red blood cells or the red blood cells do not have enough hemoglobin; the red blood cells therefore have poor oxygen-carrying capacity

o   Sickle Cell anemia – hereditary blood disorder in which the body produces red blood cells that are rigid and sickle-shaped causing blockage of small blood vessels. Symptoms may include sudden onset of severe pain, shortness of breath, and serious infections

•       Bacteremia – the presence of bacteria in the bloodstream

•       Euvolemic (adj. euvolemic) – presence of the proper amount of blood in the body

•       Hypovolemia (adj. hypovolemic) – decrease in the volume of blood 

•       Immune Thrombocytopenia Purpura (Idiopathic Thrombocytopenia Purpura, ITP) – an autoimmune disorder in which the immune system attacks platelets; symptoms include development of purpura and petechiae and excessive bleeding during injury; can lead to serious complications such as anemia and intracranial hemorrhage 

•       Leukocytosis – an abnormal increase in the number of white blood cells in the blood, commonly associated with bacterial infections

o   Bandemia – an abnormal increase in the number of band cells (immature white blood cells)

•       Leukopenia – an abnormal decrease in the number of total white blood cells in the blood o Neutropenia – a subset of leukopenia; an abnormal decrease in neutrophils in the blood 

•       Rhabdomyolysis – a potentially life-threatening condition caused by the rapid breakdown of muscle tissue and the release of intracellular muscle components such as creatine kinase and lactate dehydrogenase; can lead to electrolyte imbalances or acute kidney injury 

•       Sepsis (adj. septic) – a life-threatening, generalized immune response due to an infection; the immune response causes widespread inflammation leading to organ damage and/or failure; symptoms can include tachycardia, fever, shortness of breath, diaphoresis, and pain

Each hospital has its own Sepsis Protocol (a treatment plan for sepsis). Become familiar with this protocol and document all necessary and required information in the physician note. 

If the sepsis is severe, patients may be diagnosed with Severe Sepsis or Septic Shock. Communicate with your clinician to document the most specific diagnosis possible.

•       Thrombocytopenia – a low platelet count in the blood

•       Varices – abnormally dilated blood vessels which may leak or rupture  o Esophageal Varices – occur in the esophagus and develop due to obstruction of blood flow to the liver; common in patients with liver disease.

NEONATAL / PEDIATRIC TERMS

Many physical examination findings discussed in previous sections can also be found in pediatric patients; the following information is specific to, or more common in, Pediatric patients.

•       Pediatric – the pediatric age range is typically defined as birth to 18 years of age (or alternatively 21 years of age)  

•       Gestation – the period between conception and birth; a typical gestation lasts 37-42 weeks o Full-term – an infant born at 37-42 weeks gestation o Preterm – an infant born at less than 37 weeks gestation o Post term – an infant born at greater than 42 weeks gestation o Neonate – through the first 28 days after birth o Post-neonatal – 29^th day after birth to the first year

•       Infant – the period of time from birth through to 1-2 years of age

•       Child – typically, any patient above the age of 1-2 years of age

For infants and young children, the clinician may ask the parent/guardian about the following, depending on the age of the patient and the patient’s complaint:

•       Birth history:

o   APGAR score at birth – assessment of the neonate for immediate adaptation to extrauterine life; scoring is done at 1 minute and at 5 minutes after birth; rating is done in

5 categories including heart rate, respiratory effort, muscle tone, irritability, and color o The gestation and/or number of weeks at which the patient was born o Whether the patient was born via a normal spontaneous vaginal delivery or via C-section o The weight of the patient in pounds and ounces

o   Any complications during the pregnancy or birth for the mother and/or patient

§  Mother: preeclampsia, eclampsia, gestational Diabetes, infections, excessive bleeding, etc.

§  Patient: malposition (such as breech), nuchal cord, shoulder dystocia, etc. o Whether after birth the patient was admitted to the Neonatal Intensive Care Unit (NICU)

•       Nutrition (infants) – whether the patient is breast fed or bottle fed; some clinicians prefer to include how much the patient feeds, how often, and what formula is applicable

•       Vaccination status – children receive immunizations on a predetermined schedule; typically, the clinician will ask if the patient is up to date on the vaccines; if the patient is not up to date, the clinician will ask what immunizations the patient has yet to receive and the reason they have not received them

 The above questions may play a role in terms of the treatment plan of the patient. When writing a physician note for a pediatric patient – especially at a site with a Pediatric ED or Pediatric floor – communicate with the clinician to thoroughly document the patient’s birth history, nutrition, and vaccination status if applicable.

For pre-pubescent or pubescent children, the clinician may indicate the following: 

•       Menarche – the first occurrence of menstruation o Premenarchal – the period of time preceding the first menstruation Physical Exam Findings Specific to Infants:

•       Umbilical cord stump site – in a newborn; clinician will check the appearance of the site

•       Fontanel – the “soft spots” of the skull in between the bones in a newborn (usually closes by 2 years of age)

Other Physical Exam Findings: 

•       Generalized appearance – clinicians will observe the patient’s energy level, if the patient is cooperative, if the patient interacts appropriately with the clinician, if the patient appears well-hydrated, and/or if the patient is consolable by the caretaker; they may also want the patient’s behavior documented (i.e. the patient is watching TV)

•       Hydration status – clinicians can determine hydration status by noting if the patient produces tears when they cry and/or by asking about urine output/the number of wet diapers 

•       Pediatrics signs of respiratory distress - nasal flaring, grunting, retractions, tachypnea

•       PECARN – an algorithm to calculate the risk of clinically important traumatic brain injuries (ciTBIs) in head trauma for pediatric patients; clinicians will use this algorithm to determine if they should observe the patient for change in behavior or order a CT of the head

•       Tanner scale – a 5-point scale that describes the onset and progression of puberty changes in males and females

 If child abuse is suspected or confirmed, pediatric patients will be brought to the ED by a caretaker or the police to be evaluated. The clinician also may notice signs of abuse during physical examination, prompting further investigation. In these cases, the incident must be reported immediately to the Department of Social Services, and the patient must be held in the ED or hospitalized until the patient is medically cleared and a Child Protective Services (CPS) Officer takes over management of the case to place the patient in a safe environment. The clinician will obtain a very thorough history from the caretaker or law enforcement. They will then perform an extremely thorough physical examination including examination of the genital area, inside the mouth, and between the digits of the hands and feet. They will observe for any injuries such as lesions, burns, bruises, fractures, or head trauma. If clinically indicated, they will also perform relevant diagnostics such as bloodwork, X-Rays, or CTs. For these cases, CIMs should work closely with the clinician to accurately document the patient’s evaluation and any conversations with law enforcement and/or CPS. 

Common Complaints and Conditions in Pediatric Patients: 

Skin:

•       Burns  

•       Lesions/Rashes  o Diaper Dermatitis/Candidiasis (diaper rash) – a common form of inflamed skin in or around the diaper area

•       Varicella (chicken pox) – highly contagious viral infection that causes an itchy rash with small, fluid-filled blister

•       Pediculosis Capitis – head lice

•       Lacerations 

•       Jaundice/elevated bilirubin  HENT/Respiratory:

•       Foreign body in nose or ears  

•       Otitis Media (OM)  

•       Pharyngitis (including “strep throat”)  

•       Asthma  

•       Bronchiolitis – viral respiratory tract infection that involves the inflammation of the small terminal bronchioles; commonly caused by Respiratory Syncytial Virus (RSV); typically seen in children ages 2 and younger.

o RSV – a common virus which causes URI symptoms

•       Croup (laryngotracheobronchitis)  

•       Pertussis (Whooping Cough) – a highly contagious respiratory tract infection marked by a severe hacking cough followed by a high-pitched intake of breath “whooping”; less common due to the Pertussis vaccine

Gastrointestinal:

•       Appendicitis  

•       Cyclic Vomiting Syndrome – a disorder characterized by episodes of severe, reoccurring nausea and vomiting that have no apparent cause

•       Colic – periods of unexplained irritability and intense crying in infants, associated with abdominal pain

•       Foreign body ingestion – pediatric patients occasionally ingest foreign bodies such as coins or toys 

•       Gastroenteritis 

•       Intussusception – a condition where a portion of the intestine folds or slides into an adjacent section of the intestine; can cause intestinal obstruction, infection, and/or bleeding. Pain characteristically comes and goes 

•       Pyloric Stenosis – a condition in infants where narrowing of the pylorus (the opening from the stomach into the small intestine) prevents food from passing into the intestine; the most common symptom is projectile vomiting; easily corrected with a simple surgery

Genitourinary:

•       Urinary Tract Infection (most common in girls) 

•       Kidney disease 

•       Testicular and ovarian torsion 

Musculoskeletal:

•       Hair tourniquet – caused by a strand of hair or thread wrapping around a body part (typically the fingers and toes), causing pain and swelling; many infants present with inconsolable crying and no other symptoms

•       Fractures and dislocations:  

o   Facial fractures such as periorbital fractures and nasal bone fractures o Elbow fractures:

§  Supracondylar fracture – fracture of the distal humerus just above the elbow joint

§  Lateral condyle fracture – fracture of the lateral condyle of the distal humerus

§  Medial epicondyle fracture – fracture or avulsion of the medial epicondyle of the

distal humerus

o   Greenstick fracture – fracture caused by the bone bending and then breaking; common in children due to the soft, porous nature of children’s bones 

o   Plastic deformation (bowing) fracture – occurs when a (typical long) bone bends but does not break or compress

o   Radial Head subluxation (Nursemaid’s Elbow) – the elbow is pulled and the radial head is partially dislocated; it is easily reduced by manipulating the arm and hand

o   Salter-Harris fracture – a fracture through a growth plate of the bone; there are five types of Salter-Harris fracture (type dependent on the location of the fracture)

o   Toddler’s fracture – nondisplaced, spiral fracture of the distal tibia o Torus (Buckle) fracture – an incomplete fracture caused by one side of the bone bending and compressing but not breaking; often occurs in the distal radius

Neurologic/Psychiatric:

•       Absent and Febrile seizures  

•       Attention-Deficit/Hyperactivity Disorder (ADHD) 

•       Autism Spectrum Disorder (ASD) 

•       Head Trauma – the clinician will evaluate for swelling, tenderness, bony defects, Battle’s sign, hemotympanum, epistaxis and in infants the fontanels; will most likely evaluate using the PECARN algorithm; clinicians will ask the patient’s caretaker if they cried immediately, if they were consolable, if the vomited, and if they have been acting appropriately

•       Meningitis  

 Hematologic/Lymphatic/Immunologic:

•       Immune Thrombocytopenia Purpura (Idiopathic Thrombocytopenia Purpura, ITP)

•       Kawasaki Disease - a rare syndrome which inflames the blood vessels in the body; symptoms include high fever, swollen lymph nodes, a diffuse redness and rash; and a red, swollen tongue (“strawberry tongue”)  

•       Sickle Cell Anemia  

General:

•       Allergic reaction  

•       Breath-hold spell – an episode in which a patient involuntarily stops breathing and loses consciousness for a short period after an emotionally upsetting event or painful experience

•       Brief Resolved Unexplained Event (BRUE) – an event where an infant younger than 1years-old stops breathing and becomes unresponsive; the patient may have a change in muscle tone and become pale or cyanotic; it is only diagnosed when there is no explanation for the event after a thorough examination; previously known as an Apparent LifeThreatening Event (ALTE)

•       Hand, Foot, and Mouth Disease – a viral infection caused by a strain of Coxsackievirus; symptoms include ulcers typically on or in the mouth, hands and arms, feet and legs; fever; sore throat; and fatigue

•       Multisystem Inflammatory Syndrome – a rare but serious inflammatory condition seen in children that is linked to COVID-19; shares some similarities to Kawasaki disease; patients have fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization with multisystem organ involvement

DIAGNOSTICS

During most ED visits, the clinician will deem it necessary to order one or more diagnostic tests to determine the cause of the patient’s symptoms. The diagnostics ordered will be based on the patient’s chief complaint, past medical history, and/or physical examination findings.

This section of the manual highlights CIM responsibilities regarding diagnostics and common diagnostic tests and their documentation requirements. This section is not an exhaustive list. Communicate with your clinician to learn the documentation for any diagnostics not listed.

Regarding Diagnostics, CIMs are responsible for the following:

1.     Monitoring the status of diagnostic test results throughout the shift – Each patient will have a different set of diagnostics ordered. It is recommended that a CIM create a list (typed or written) of the diagnostics ordered for each patient and use it to track which diagnostics have resulted and which are still pending.

2.     Informing the clinician when a diagnostic has resulted, especially if the result is abnormal – Abnormal diagnostic results can directly influence the clinician’s medicaldecision making. For example, a patient with an elevated White Blood Cell Count may have an infection which the clinician treats with antibiotics. For abnormal diagnostic results, document the time they resulted and the clinician’s decision-making in the Emergency Department Course and Treatment section of the physician note.

The laboratory or radiologist may call the ED to inform the medical staff of a critical result (a result that reflects a life-threatening abnormality). These calls may only be taken by nurses and clinicians. CIMs should include the time of the call and the pertinent information in the Emergency Department Course and Treatment.

Noting which diagnostics are typically ordered for a symptom (e.g., chest pain, shortness of breath, probable infection, etc.) will make it easier to track diagnostic results and learn what is considered “abnormal” for those diagnostics. 

3.     Confirming all diagnostic results are documented within the physician note – Most sites have an interface between the EMR, the laboratory, and/or radiology department which automatically pastes diagnostic results into the physician note. Not all results populate automatically, however, and those results must be manually entered by the CIM.  

4.     Recognizing, troubleshooting, and communicating potential delays in diagnostic results – A CIM should be the first person to notice a delay in results. If an issue is identified, check to see if the order was entered or cancelled; speak with the primary nurse to confirm if a sample was sent to the lab or if a patient was sent for imaging; and/or contact the lab or IT team to resolve the issue. Inform the clinician of the delay, the steps

you have taken to resolve it, and when the diagnostic is likely to result.

 When asking a question to a member of the ED care team or hospital, speak clearly and appropriately identify the patient and specific test that is delayed. Ensure the individual is not on the phone or speaking with another clinician when you approach them – be considerate.

Different diagnostics in the ED have specific documentation requirements, but generally include: 

•       Name of the test performed

•       Impression/result of the test

•       Interpreting clinician (for EKGs and Radiographic Imaging) 

The name and results of all studies are documented within the Diagnostic section of the physician note in list format (e.g., each study and its result is documented on a new line). 

                   For Example:

                    DIAGNOSTICS:

Pulse Oximetry:  98% on RA indicating adequate oxygenation.

EKG:  NSR at 86 BPM, with normal axis, normal intervals, (-) acute ST-T wave changes as interpreted by me.

CXR: (+) RML infiltrate, (-) cardiomegaly as interpreted by me.

CT Head: (-) acute hemorrhage, (+) old basal ganglia infarct; as interpreted by radiologist, Dr. Smith.

 Depending on the EMR, pre-populated diagnostic results may need to be edited or deleted from the template based upon the clinician’s orders or the results of diagnostics.

                   For Example:

            The template you chose for a patient prompts you to document an EKG, but one is not  performed on the patient. You would delete the EKG prompt from the template.

The template has a pre-populated Chest X-Ray interpretation that states “(-) infiltrates, (-) effusions, (-) pneumothorax” but the clinician dictates “(+) right lower lobe infiltrate, (-) CHF”. You would delete “(-) infiltrates, (-) effusions, (-) pneumothorax” from the template and document “(+) right lower lobe infiltrate, (-) CHF”.

Diagnostic tests ordered in the ED include Laboratory Specimens, Cultures, Radiology, and Cardiac Studies.

LABORATORY SPECIMENS (LABS)

Labs are samples of biological substances such as blood or urine that are analyzed to help diagnose disease. The clinician orders the studies, and the specimens are usually obtained by a nurse, although clinicians can obtain these specimens if needed. Most samples are then sent to the hospital laboratory, excluding Point-of-Care tests (see below).

In the laboratory, the sample is analyzed and then compared against a reference range. For example, at the time of writing this, a normal Blood Urea Nitrogen (BUN) is anywhere from 6 – 24 mg/dL; any value outside this range would be considered abnormal. For some labs, “abnormal” can simply be the presence or absence of something, such as bacteria or protein.

Many EMRs have symbols or colors to denote normal versus abnormal lab results; perhaps a normal result is highlighted in green while an abnormal result is highlighted in red. The EMR will also display the patient’s result and the reference range utilized.

It is important to note that reference ranges can differ from hospital to hospital and can change over time with research. A patient’s history will also change what is considered “abnormal” for the patient. For example, a patient with Type II Diabetes may have a slightly higher blood glucose at baseline than the normal range. A CIM is not responsible for interpreting lab results – that is the role of the clinician.

 A clinician may want to compare (trend) lab values from a patient’s previous records or previous ED visits. If a patient presents with a complaint for which they have previously been evaluated (for example, chronic anemia) save the clinician time by having this information readily available for review.

Below is a review of the common labs you will see performed in the ED. It is important to understand what organ or system each lab tests and what abnormalities each lab can indicate.

Common Blood Tests

Complete Blood Count (CBC) – tests the cells of the hematological (blood) system; it can also help detect a wide range of disease. The most important components of the CBC are: 

•       White Blood Count (WBC) – the total number of WBCs (leukocytes); can detect leukocytosis and leukopenia

o   WBC Differential – measures the number of each leukocyte; certain leukocytes are more active for different types of infections or injuries.

•       Hemoglobin and Hematocrit (H&H or H/H) – abnormally low values can indicate anemia.

o   Hemoglobin (Hgb) – rapid indirect measurement of the red blood cell (RBC) count.

Hgb serves as the vehicle for the transport of oxygen and carbon dioxide.

o   Hematocrit – the number of the number of red blood cells as compared to the total blood volume (RBCs and plasma) expressed as a percentage.

•       Platelet count – the total number of platelets (thrombocytes). Platelets are essential for blood clotting; thrombocytopenia (low platelet count) can be caused by chemotherapy, leukemia, viral infections, some types of anemia, or anticoagulants.

Additional Hematologic Labs – these test other functions of the hematological system

•       Coagulation studies (Coags) – tests that measure how long it takes the blood to coagulate (clot). The most common Coags are:

o   Prothrombin Time (PT)

o   International Normalized Ration (INR) – often ordered with PT as a PT/INR o Partial Thromboplastin Time (PTT)

•       D-Dimer – a blood test that measures the breakdown products of an embolus; therefore, it can be elevated due to the presence of an embolus. It can also be caused, however by recent surgery or trauma, some cancers, liver or kidney disease, and in pregnancy.

•       Erythrocyte sedimentation rate (ESR) – a non-specific test used to detect acute and chronic infection, inflammation, or tissue injury; measures how quickly erythrocytes settle in a test tube.

•       C-Reactive Protein (CRP) – another non-specific test to detect inflammation or injury.

An increased PT/INR/PTT means the blood is taking longer to clot (the blood is “thin”). Common causes include anticoagulant use, a Vitamin K deficiency, liver disease, or bloodclotting disorders. A decreased PT/INR or PTT means the blood is clotting too quickly; this is less common. 

Because of the different coagulation pathways, each anticoagulant has a different effect on the coagulation studies. PT/INR is increased by Coumadin while the PTT is increased due to Heparin or Warfarin. These tests are therefore ordered to monitor anticoagulation therapy over time.

Cardiac Labs – these tests indicate potential damage or stress to the heart.

•       Troponin – a protein found in heart muscle that assists in contraction; it is released from the muscle when the heart is injured; an elevated Troponin is common in an MI.

•       Creatine phosphokinase (CPK) – an enzyme released by the heart when it is injured; it can be elevated in acute cardiac injury but is less specific as other inflammation can cause an elevated CPK.

•       B-type Natriuretic Peptide (BNP) – a hormone secreted by the heart in response to excessive blood volume and pressure in the ventricles; an increased BNP is very common in heart failure, especially CHF.

When a patient presents with symptoms of an MI, a Troponin is one of the first and most important tests performed. Be sure to track this lab carefully and notify the clinician when it has resulted.

Pancreatic Labs – the two enzymes below, Amylase and Lipase, are tested to assess the function of the pancreas. If the enzymes levels are elevated, it indicates injury or inflammation of the pancreas. They are commonly ordered for patients with abdominal pain. 

•       Amylase – enzyme used by the pancreas to digest carbohydrates.

•       Lipase – enzyme used by the pancreas to digest dietary fats.

Liver Function Tests (LFTs) – the liver performs many important functions including producing bile, important proteins, and other substances; regulating blood clotting; and filtering the blood of wastes such as drugs or bilirubin, a pigment made during the breakdown of RBCs.

The following tests evaluate liver function:

•       Albumin – a protein synthesized by the liver which enters the bloodstream and assists in fluid balance and carrying important molecules. Low albumin levels can indicate liver damage.

•       Alkaline Phosphatase (ALP) – a liver enzyme that is associated with the biliary tract. If elevated, biliary tract damage or inflammation is considered.

•       ALT (alanine aminotransferase) – an enzyme that is released when the liver is injured. It is the primary marker to assess for liver cell damage.

•       AST (aspartate aminotransferase) – another enzyme that is released when the liver is injured.

•       Bilirubin – tests the amount of bilirubin present in the blood; as the liver is responsible for the breakdown of bilirubin, an increased amount of bilirubin can indicate liver damage. It is a valuable measurement that helps in the differentiation of liver damage or gallbladder disease. 

o   Total Bilirubin – a measure of both unconjugated and conjugated bilirubin. Unconjugated bilirubin is transformed by the liver into conjugated bilirubin. o Direct Bilirubin – when subtracted from the total bilirubin, it provides an estimate of the amount of conjugated bilirubin. Normally, this amount is very low.

•       Total Protein – measures the amount of albumin and globulin in the blood. This test may be ordered to provide information about symptoms related to disorders of the liver, kidney, bone marrow, etc. 

 The ratio between ALT and AST is useful in assessing the etiology of liver enzyme abnormalities.

Renal Function Tests – the kidneys remove waste from the blood and are important in maintaining fluid-electrolyte balance, blood pH, and blood pressure. If they become damaged these functions may be impaired. The following tests evaluate renal function:

•       Blood Urea Nitrogen (BUN) – measures the amount of urea nitrogen (a waste product) in the blood; an increased BUN indicates kidney injury.

•       Creatinine – measures the amount of creatinine (another waste product) in the blood; an increased Creatinine indicates kidney injury.

•       Glomerular Infiltrate Rate (GFR) – glomeruli are the structures in the kidneys that filter out waste; the GFR measures how much blood passes through the glomeruli in one minute. A low GFR indicates kidney injury.

Metabolic Panels – sets of biochemical tests that provides key information regarding fluid balance and metabolism including electrolyte balance, blood sugar level, kidney function, and liver function. There are two main types of Metabolic Panels: 

•       Basic Metabolic Panel (BMP) which includes:

o   Electrolytes:

§  Sodium (Na⁺⁾ – helps regulate fluid balance and the function of nerves and muscles.

§  Potassium (K⁺) – helps regulate cardiac function and the function of other nerves and muscles. Abnormally low or high Potassium levels can increase the risk of an abnormal heart rate or rhythm.

§  Chloride (Cl^-) – helps regular fluid balance and maintain acid-base balance.

§  Carbon Dioxide (CO₂^-) or Bicarb (HCO₃^-) – measures carbon dioxide level and evaluates the blood pH. o Glucose o Renal Function Tests

§  BUN and Creatinine

•       Complete Metabolic Panel (CMP) which includes:

o   Sodium  o Potassium  o Chloride  o Carbon Dioxide/Bicarb o Glucose o Renal Function Tests:

§  BUN and Creatinine o Calcium – helps regulate the muscular, circulatory, and digestive systems o Liver Function Tests:

§  Albumin

§  Alkaline Phosphatase

§  ALT

§  AST

§  Total Bilirubin

§  Total Protein

CMP = BMP + Calcium + LFTs

Respiratory Diagnostics

Arterial Blood Gases (ABG) – an arterial blood sample taken that reflects the pH and oxygenation of the arterial blood. It can be used to analyze the patient’s respiratory, metabolic, and renal status. ABGs are performed in the ED by a respiratory therapist or an ED clinician.

ABGs can include:

•       pH – blood pH. A normal blood pH is from 7.35 to 7.45.

•       Partial pressure of O2 (pO2) – how well O2 moves from the lungs to blood.

•       Partial pressure of CO2 (pCO2) – how well CO2 is removed from blood.

•       HCO3 – a chemical that prevents blood from becoming too acidic or basic.

•       O2 saturation – the percentage of hemoglobin saturated with oxygen.

Pulse Oximetry (Pulse Ox) – another test to measure O2 saturation. A Pulse Ox is taken using an electronic device placed on the patient. When documenting the Pulse Ox, the percentage, adequacy, and route of oxygen administration must be documented. 

Routes include Room Air (RA), Nasal Cannula (NC), Nonrebreather Mask (NRB), BiPAP, and ventilator (vent). With NCs and NRBs, the amount of O2 being given to the patient should be documented. 

                   For Example:

                            Pulse Ox: 98% on O2 2 L via NC indicating adequate oxygenation.

The Pulse Ox is typically included in the triage note with the vitals but is documented in the Diagnostics. 

 If a patient’s Pulse Ox is low, the clinician’s plan to treat it should be documented in the note.

 It is a CIM’s responsibility to confirm the Pulse Ox reading is correctly documented in the note. The ED clinician is the only individual who can interpret the adequacy of oxygenation for the physician note. Adequacy may change based on a patient’s health status or ED clinician preferences. For example, a patient with COPD may have a baseline oxygenation of 90%, and the clinician may deem that adequate for the patient. Always confirm the Pulse Ox information with the clinician before documenting it in the note.

Other Blood Tests and CSF Analysis

Beta Human Chorionic Gonadotropin (Beta HCG/BHCG) – measures the amount of HCG

present in a patient’s blood, which can assess the progression of a pregnancy. It is considered the quantitative pregnancy test (for qualitative test, see UHCG below).

Blood Drug Level – blood test that detects the blood concentration of a drug. For prescription medication, it is to determine if blood levels are within the therapeutic range (the blood levels where the medication has the desired effect), subtherapeutic range (blood levels are too low), or supratherapeutic range (blood levels are too high). A subtherapeutic or supratherapeutic medication blood level can cause serious side effects.

•       Common prescription drug levels include: o Antibiotics: Vancomycin, Gentamycin o Heart Drugs: Digoxin (Digitalis), Procainamide

o   Anti-Seizure Drugs: Valproic Acid (Depakote), Phenytoin (Dilantin), Phenobarbital,

Carbamazepine (Tegretol), Levetiracetam (Keppra) o Drugs that treat Bipolar Disorder: Lithium, Valproic Acid (Depakote)

•       The following blood levels are commonly tested in suspected overdoses or poisonings:

o   Acetaminophen (Tylenol) o Salicylate (Aspirin)  o Ethanol (EtOH) level/Blood Alcohol Level (BAL) o Barbiturates: Donnatal, Fioricet, Phenobarbital, etc. o Lead (Pb)

 Drug levels may not result during the patient’s visit. If this is the case, document that it is obtained and pending (ex: Keppra level obtained and pending) in the Diagnostics section.

Carboxyhemoglobin (COHb) – blood test that detects carbon monoxide poisoning.

Cerebrospinal fluid (CSF) Analysis – analysis of the fluid that surrounds the brain and spinal cord. It is typically clear and does not contain WBCs; an abnormal color or presence of WBCs can indicate infection or injury. A sample of CSF is obtained through a lumbar puncture (LP).

Hemoccult (Guaiac) Test – tests for hidden blood in the stool (“heme” – blood; “occult” – hidden). This test involves placing a small fecal sample on Guaiac paper and applying hydrogen peroxide. The paper will turn blue if blood is present. The result of the Hemoccult test is documented in the physical examination.

Lactate/Lactic Acid – a blood test for detecting lactate/lactic acid, which is a substance produced by RBCs and tissues when oxygens levels decrease. This can be caused by strenuous exercise, but also by acute heart injury, severe infections, sepsis, or shock. 

Lyme Titer – blood test that detects Lyme disease antibodies.

Mono-spot – blood test that detects Mononucleosis antibodies. 

Urine Tests and Point-of-Care (POC) Tests

Urine dipstick (Urine dip) – a test performed at the bedside which detects the presence or absence of abnormal substances in urine (e.g., blood, nitrites, sugar, protein, leukocytes, etc.).

Urinalysis (U/A) – a microscopic examination of urine in the laboratory that identifies any abnormal substances in the urine and quantifies them; for example, a U/A can tell the clinician that leukocytes are present and give an estimate on how many cells are present in the sample.

Urine HCG (UHCG, urine pregnancy test) – detects HCG in urine, yielding either a “positive” or “negative” result. As it only tells the clinician whether the patient is pregnant, rather than the progression of pregnancy, it is the qualitative pregnancy test.

Any female of child-bearing age must complete a pregnancy test or sign a waiver before the administration of certain medications or diagnostic imaging with exposure to radiation. 

Urine Drug Screen (UDS) – a qualitative test that detects drugs in the urine such as: 

                      Marijuana (cannabis)/THC                                       Cocaine

                      Phencyclidine (PCP)                                                               Amphetamines

Morphine                                                         Narcotics/Opiates Heavy Metals (Mercury, Arsenic, Bismuth)  Barbiturates 

Point-of-Care (POC) Tests – Medical tests which are performed – and result – at the point-ofcare, which is the patient’s bedside. Results return rapidly and conveniently but may be less accurate than a diagnostic sent to the lab. They are typically performed by the nurse or patient care technician, but the ED clinician can perform them as well.  Examples of POC Tests include:

•       Urine dip

•       UHCG

•       Finger stick blood sugar (FSBS)

•       Rapid antigen tests such as Rapid Strep, Rapid Influenza, Rapid COVID-19

•       Hemoccult/Guaiac test

•       i-STAT – A handheld blood analyzer that provides rapid results for Troponin,

Hematocrit, BUN, pH, blood gasses, electrolytes, and glucose. Commonly ordered when an ST-Elevation MI (STEMI) is suspected to quickly evaluate the Troponin.

POC tests may not cross over to the EMR and may require manual entry into the physician note.

CULTURES

Most biological substances such as blood and urine are anexic or sterile – microbes are not present in these substances. Other substances such as stool contain microbes, but a disturbance in the balance of the microbe population can lead to infection.

A clinician can order a culture to detect infection and determine the microbe responsible for the infection in biological substances. Identifying the microbe can help tailor the patient’s treatment. For example, different medications are used to treat bacteria, fungi, and parasites, and some antibiotics are more effective against one strain of bacteria versus another. 

In a culture, a sample of a biological substance is taken and placed into a medium where the infectious microbe can grow and multiply. The laboratory staff will then identify the microbe based on the physical characteristics of the microbe colonies and the conditions in which the microbe grows. Typically, one aerobic and one anerobic culture is taken.

•       Aerobic Culture – detects microbes that grow in the presence of oxygen 

•       Anaerobic Culture – detects microbes that grow in the absence of oxygen

 Cultures take up to 48-72 hours to result and therefore results will not typically be available during a patient’s ED visit. If ordered, cultures are documented as obtained and pending (ex: Blood cultures obtained and pending) in the Diagnostics section. When results return, they are appended to the physician note by either a CIM or ED clinician.

Common types of cultures include:

•       Blood Culture

•       Urine Culture

•       Stool Cultures – Normal GI microbes can become pathogenic if there is overgrowth of any microbe. In addition, the GI tract is a common location for parasites.

o   Culture and Sensitivity (C&S)

o   C. difficile (C. diff) Culture – detects Clostridium difficile, a bacterium that causes severe colitis, diarrhea, and dehydration o Ova and Parasite (O&P)

•       Sputum Culture – Detects microbes in the respiratory tract

•       Wound Culture

•       Fluid Cultures o CSF Culture

o   Pleural Fluid Culture – Collected from the pleural space during thoracentesis o Peritoneal Fluid Culture – Collected from the peritoneal cavity during paracentesis o Joint/Synovial Fluid Culture – Collected from the affected joint (typically the knee, shoulder, ankle, elbow, or hip) during arthrocentesis

RADIOLOGY

Radiographic studies are images of internal structures such as organs or bones. The ED clinician will determine which radiographic studies are indicated based on the subjective and objective information they obtain from the patient during the ED visit. 

All radiographic studies are interpreted by the ED clinician or an attending radiologist. The individual who interprets a study will change based on many factors, including time of day, day of the week, and the number of patients in the ED and Radiology Department. For example, a resident or off-site radiologist may provide the interpretations if the radiology attending is not present in the hospital.

ED clinicians typically open and view X-Ray results through the hospital’s Picture Archiving and Communication System (PACS). They will then enter in their preliminary interpretation into PACS. All other radiographic studies are usually interpreted by a radiologist.

CIMs must document the results and/or interpretation and who interpreted the study in the physician note. The phrase “as interpreted by me” or “as interpreted by Title/Name” can be used when an ED clinician interprets the study. If interpreted by a radiologist, utilize the phrase “as interpreted by radiologist, Title/Name”.

For Example:

DIAGNOSTICS:

X-Ray of the Left Humerus: (-) fracture, (-) dislocation as interpreted by me.

Chest X-Ray: (-) infiltrate or effusions as interpreted by Gloria Lee, PA-C.

CT of the Abdomen and Pelvis: (+) fatty liver, (+) umbilical hernia, (-) evidence of diverticulitis or other acute inflammatory process as interpreted by Dr. Smith, radiologist.

 Some radiographic studies are performed at the bedside; for other studies, the patient is brought to the Radiology Department. Maintain awareness of when radiographic equipment is brought into a patient’s room or when a patient is brought to Radiology for imaging. When results have returned, notify your clinician, and document the results in the note.

The most common radiographic studies ordered in the ED are X-Rays, Computed Tomography (CT) Scans, and Ultrasounds. In the following sections, the most common subtypes for each radiographic study will be discussed as well. Please note these lists are not comprehensive, and additional radiographic studies may be ordered in your ED.

X-Rays

X-rays are 2-dimensional black-and-white films produced using electromagnetic wave radiation. Radiopaque structures (structures that the radiation cannot pass through) such as bones or foreign objects will appear as white. Radiolucent structures such as muscle or tissue will appear as dark grey or black.  X-ray images can be viewed through PACS.

Portable X-Rays are a type of X-Ray taken at the patient’s bedside using a portable X-Ray machine. While portable X-Rays may not be as high in quality as an X-Ray performed in the Radiology department, they are suitable for patients who cannot be moved or properly positioned.

Typically, multiple views/projections are obtained to visualize all structures clearly. Common XRay views include:

•       Anteroposterior (AP) and Posteroanterior (PA) – both provide a frontal view of the areas being imaged

•       Lateral – provides a side view and allows the clinician to observe areas that can be obstructed in an AP or PA view (for example, behind the heart on a Chest X-Ray)

•       Oblique – the patient or area being imaged is rotated 45 degrees

•       Supine – the patient lies on their back for the imaging

•       Erect – the patient is standing for the imaging

Required documentation for X-Rays include: 

•       Name of the study

•       Views obtained/laterality of the study, if applicable

•       The clinician’s interpretation

•       The clinician who interpreted the study i.e., “as interpreted by me” or “as interpreted by Name/Title”

For Example:

Chest X-Ray: (+) cardiomegaly, (+) alveolar edema, (+) haziness of vascular margins as interpreted by me.

Chest X-Ray (CXR) - Visualizes the heart, lungs, trachea, diaphragm, and skeletal structures of the chest; typically ordered for patients experiencing chest pain or shortness of breath. Common views for a CXR include PA and Lateral views. An AP view can be obtained but results in poorer quality images.

Common findings on CXRs include:

•       Atelectasis – a complete or partial collapse of the lung

•       Aortic aneurysms or dissections

•       Calcifications – hardening of the soft tissue of the lungs or heart

•       Cardiomegaly – enlargement of the heart

•       Central line/Central venous catheter placement – after placing a central line, the ED clinician will order a CXR to confirm the line is in the correct location

•       Chronic Obstructive Pulmonary Disease (COPD)

•       Congestive Heart Failure (CHF)

•       Consolidation(s) – fluid such as edema (from CHF or water inhalation), pus (from pneumonia), blood, etc. that has filled the alveoli and small airways of the lungs o Consolidation(s) might also be referred to as edema, infiltrate(s), or opacities.

o   Consolidations/infiltrates/opacities may be described using their appearance, such as “ground-glass opacities”.

•       Devices such as defibrillators, pacemakers, and valve replacements

•       Effusions (pleural or pericardial) – when excess fluid accumulates in the pleural or pericardial spaces

•       Endotracheal tube (ET tube) placement – after inserting an ET tube, the ED clinician will order a CXR to confirm the ET tube is in the correct location

•       Free air in abdomen (pneumoperitoneum) – an abnormal collection of air in the abdomen typically due to a perforation of the GI tract

•       Foreign bodies

•       Haziness of the lung fields

•       Hyperinflation – lungs that are larger than normal due to trapped air, common in COPD

•       Pneumonia

•       Pneumothorax – when air collects in the pleural space between the chest wall and the lung; the collection of air prevents the lung from inflating

o   Deep sulcus sign – an abnormally deep costophrenic angle on supine CXR; an indication of a pneumothorax

•       Rib fractures – clinicians will note which ribs are affected

•       Silhouette sign – a loss of visible borders between the heart, aorta, and/or diaphragm; can be caused by a mass or a consolidation, such as lower lobe pneumonia

•       Solid masses such as nodules which may be benign or indicative of cancer/malignancy