Patient Note

Question 1

HEENT Short PE Report

Answer 1

-HEENT: NC/AT; no cyanosis icterus or pallor; moist and pink oral and nasal mucous membranes, no oral ulcers, good dentition; no pharyngeal erythema, exudates or enlargements. Neck is supple with no palpable masses or thyromegaly.

Question 2

Extremity Short PE Report

Answer 2

-EXT: no pain or swelling, no changes in color or temperature; pulses 2+ and symmetrical in all ext.; capillary refill <2 sec.

Question 3

Cardiovascular Short PE Report

Answer 3

-CV: RRR, S1S2 WNL, no MRG

Question 4

Chest Short PE Report

Answer 4

-CHEST: No abnormalities on inspection, CTAB; no rales or ronchi

Question 5

Abdomen Short PE Report

Answer 5

-ABD: soft, nontender, nondistended, BS+, no bruits or palpable masses.

Question 6

PE Intro

Answer 6

-Px appears comfortable and is in NAD. VS WNL, except for BP/RR/HR/T.

Question 7

Abdomen Extended Report

Answer 7

-ABD: symmetrical with no anomalies on inspection; tympanic throughout; soft, nontender, nondistended; BS+, no bruits; no HSM, palpable masses or CVA tenderness; Neg RT/Rovsing/Psoas or obturator sign/Murphy/Pain at McBurney’s point.

Question 8

Chest Extended Report

Answer 8

-Chest: no anomalies on visual inspection; excursion/TVF WNL; nontender; CTAP B/L; no rales or ronchi