Total Medical Transcriptionist Guide

PHYSICAL EXAMINATION TERMS/PHRASES (SECTION WISE):
GENERAL / GENERAL APPEARANCE:
A&O x3
agitated
ambulatory
Apgar score
blank, staring, expressionless face
cachectic
Cheyne-Stokes breathing
chronological age (younger/older than chronological age)
comatose
conscious
cushingoid
depleted nutritionally
diaphoretic
disheveled
elderly, frail
engages with the examiner without difficulty
engaging appropriately
insight to current problem
language disturbance
intubated and sedated
lucid and follows commands
lying in semi-Fowler position
malaise
mask facies
no acute distress
obtunded
orthostatic changes
postanesthesia drowsiness
slurred speech
The patient appears fatigued.
The patient has slurred speech and abruptness of speech.
The patient is a cachectic male/female.
The patient is a pleasant, cooperative, overweight male/female.
The patient is a well-built elderly/young/middle-aged male/female.
The patient is a well-developed, well-nourished male/female.
The patient is alert, awake, and oriented.
The patient is ill appearing.
The patient is in no acute distress, resting comfortably in bed.
The patient is intubated.
The patient is lethargic, confused.
The patient is malnourished.
The patient is moaning and groaning.
The patient is nontoxic, calm, conversant
The patient is responsive to commands. He is following commands verbally.
The patient is lying on a gurney in the emergency room
undue distress
vocabulary
WDWN (well-developed, well-nourished)
wearing glasses
well hydrated

VITAL SIGNS:
blood pressure
BMI (body mass index).
height
O2 saturation
pulse/heart rate
respirations or respiratory rate
T-max
weight

HEENT: HEAD, EYES, EARS, NOSE, THROAT
agnathia

allergic salute

alopecia

allergic shiners

alopecia noted

anicteric sclerae

anisocoria

anterior tonsillar pillars are red

aphthae

aphthous ulcers

arcus senilis

AV nicking

Battle's sign

best-corrected visual acuity

bifid

bifid uvula

bifocals (wears bifocals)

boggy turbinates

buccal mucosa

bulbar conjunctivae

cataracts

cleft palate

cobblestoning

conjunctivae pink

conjunctivitis

cornea clear/cloudy

corneal reflex intact

Cowden disease

crowded oropharynx

Dennie-Morgan lines /Dennie-Morgan fold

dental caries

dental hygiene

dentition

dentures

deviation of mouth

disk margins well-delineated

disks sharp

dysconjugate gaze

ears have mild cerumen or no cerumen

edentulous

effusion

elongation of soft palate

endotracheal tube

enucleated

EOMI

EOMS full. (EOMS can mean either extraocular movements or extraocular muscles)

ET (endotracheal) tube in place

external auditory canal

extraocular movements intact

extraocular muscles intact

facial droop

facial sensation is intact

flattening of the nasolabial fold

floor of mouth is nontender

fontanel (infant exam)

funduscopic exam

gag reflex

gingiva

gingival hyperplasia

glaucoma

good cone of light

Guerin fracture

hairy leukoplakia

halitosis

hard palate / soft palate

has pterygium on the eye

head trauma

helix of ear is tender to touch

homonymous hemianopsia

hypopharynx and larynx are normal

impacted molars

isocoria or isocoric

Le Fort fracture

Le Fort I fracture

Le Fort II fracture

Le Fort III fracture

lenticular opacification

leonine facies

Ludwig angina

macrocephaly / microcephaly

macular degeneration

Mallampati grade (pharynx is Mallampati grade 3)

mandibular hypoplasia

mastoid air cell tenderness

maxillary, ethmoid, frontal

micrognathia

midface and mandible are stable

moist mucous membranes

mucosa is boggy

mucosal pallor

mucositis

myringotomy tubes

nares, patent

nasal bridge

nasal flaring

nasal mucosa edematous or nonedematous

nasal passages are crowded

nasal prongs

nasolabial fold flattening

nasopharyngeal trumpet

NC/AT

NG tube or nasogastric tube

no epistaxis or epistaxis seen

no exudates, plaques or lesions

no facial lines

no field cut to gross confrontation

no hemotympanum

no papilledema, AV nicking, hemorrhages or exudates noted

no scleral icterus

no traction on the pinna

normocephalic and atraumatic

OP (oropharynx) clear

oral exam shows slight crowding

orbital, periorbital

oropharynx is clear.

oropharynx is noninjected / oropharynx is injected

palatal movements diminished

periodontal disease

PERRL

PERRLA

pharyngeal hyperemia

pharynx is crowded

pharynx pink and moist

phonation problems

Pierre Robin syndrome

pinna

plethoric facies

poor light reflex

posterior pharynx without injection

pre or postauricular nodes

puffing of eyelids

punctate exudates on tonsils

pupils are equal, round, and reactive to light and accommodation

raccoon eyes

rapid eye movements (REM)

red reflex

Rinne test

sclerae and conjunctivae are normal

septal deviation

sinuses are nontender to percussion

sinuses

slit-lamp examination

sluggish pupils

sore throat

strabismus

symmetrical vocal cord motion

temporomandibular joint

throat is clear

thrush

TMs shiny and clear

TM has a slight bulge and diffusion of cone of light

tongue congestion

tongue is dry

tongue well-papillated

tonsillar hypertrophy

tonsils (tonsils are 3+ bilaterally)

trichilemmoma

trismus (no trismus)

tympanic membranes

uvula

uvula is nonedematous

uvula moves on phonation

vermilion border

visual acuity is _____ (dictated value, usually 20/20)

visual field testing

wax impaction

Weber test

NECK:
anterior cervical lymphadenopathy
bilateral bruits conducted from the aortic areas to both carotids.
Brudzinski sign
carotids are +2/4
carotids are full
elevated JVP up to the angle of the jaw
free of masses.
goiter
hepatojugular reflux or HJR (abbrev)
JVD at 30 degrees, head up position.
meningeal irritation
meningeal signs
meningismus
neck brace.
neck collar.
neck is supple.
no bruits. No carotid bruits.
no cervical or supraclavicular lymph nodes.
no jugular venous distention / No JVD. No JVP. Jugular venous pressure is not raised
no JVD elevation.
no lymphadenopathy or thyromegaly.
no nodularity.
no thyroid enlargement.
nuchal rigidity
nuchal spasm
shotty lymph nodes (sounds "shoddy" but its shotty)
trachea central
trachea midline
tender nodes
venous distention at 45 degrees

HEART OR CARDIOVASCULAR:

A2 louder than P2
apical impulse
apical murmur
audible murmurs
grade 1/6 or 2/6 or 3/6 systolic murmur.
irregularly irregular rhythm
loud P2
loud S3 gallop
no ectopy
no extra heart sounds
no friction rub
no heave or thrill
no MR, no AI
no precordial heave
no S3 or S4 appreciated
pericardial knock
PMI is at the fifth intercostal space.
PMI is at the fourth intercostal space.
PMI is diffuse.
PMI is hyperdynamic.
PMI is not displaced.
PMI.
Point of maximal impulse.
prosthetic click/sound
Regular rate and rhythm.
RRR.
RSR
S1 normal intensity, S2 single.
S1, S2, S3, S4.
S2 snapping sound with mild mitral insufficiency
soft 2/6 or 3/6 or 1/6 systolic murmur along the left sternal border.
soft systolic murmur.
without murmur, gallop, rub or click.

CHEST:
barrel chest
expansion was symmetric
midline sternotomy scar
pigeon chest

LUNGS OR PULMONARY:
accessory muscles of respiration
adventitious sounds
costophrenic angles
crackles, wheezes, rhonchi.
crepitant rales
CTA (clear to auscultation)
diminished breath sounds.
E to A changes
equal breath sounds
good bilateral air entry.
good breath sounds.
good air exchange
hyperresonant
increased AP diameter
inspiratory, expiratory.
lung fields.
Lungs are clear to A&P.
Lungs are clear to auscultation and percussion.
no retraction
normal AP diameter
pleural rub
unlabored breathing
vesicular breath sounds
ABDOMEN:
all 4 quadrants
appendectomy scar
ascites
ballottable
Bowel sounds are active.
cesarean section/hysterectomy scar seen.
diffuse direct tenderness
epigastric bruit
fluid wave
hyperactive bowel sounds.
hypoactive bowel sounds.
liver and spleen not palpable.
liver is palpable
McBurney's point
Murphy's sign
No guarding, rebound, hepatosplenomegaly.
No masses. No hernias.
No organomegaly or masses.
Normoactive bowel sounds.
Obese, bulky.
PEG tube in place.
peristalsis
Positive bowel sounds.
protuberant.
renal angles
scaphoid abdomen
scars from previous surgery seen
scars of surgery.
soft, flat, nontender, nondistended
stoma is patent

EXTREMITIES OR MUSCULOSKELETAL:
1+ or 2+ edema.
above-knee amputation
anatomic snuffbox
ankle dorsiflexion
ankle edema.
anterior drawer sign
Apley grind test
Apley's test
arc of motion
ballotable patella
balls of feet
beats of clonus
below-knee amputation
brachial pulses are 1-2+
bunion
calcaneal cuboid
calf tenderness
capillary refill
CCE (cyanosis, clubbing or edema)
Charcot foot.
claudication
clonus
clubfoot.
"clunk" test for tib-fib
Cram test
dependent edema
DJD (degenerative joint disease)
Dorsalis pedis and posterior tibial pulses.
DP and PT pulses.
drop-arm test for rotator cuff tear
DTRs are 2+.
DTRs are brisk.
DTRs are symmetric.
DTRs are trace.
flexion contracture
flexor digitorum
footdrop
functional hallux limitus
genu valgum/genu varum
golfer's elbow test
good joint range of motion without bony deformities
gravity drawer test
grip is full
hallux valgus
Hawkins test (Hawkins impingement sign)
Heberden's nodes of osteoarthritis
hip click (infant examination)
Homans sign
Hoover sign / test
Lachman
Ludington test
McMurray's test
Mild pedal edema / trace pedal edema.
milking the knee
Moves all 4 extremities well.
Mulder sign
Neer test (Neer impingement sign)
neutral calcaneal stance
no bony or joint abnormalities
No calf tenderness.
No cellulitis.
No cyanosis, clubbing or edema.
No lymphedema.
patella apprehension test
peripheral circulation
peripheral pulses are intact
Phalen test
pitting edema.
pivot shift
plantar flexion
poststatic dyskinesia
posterior drawer sign
posterior sag sign
radial pulse
reflexes are 2+ or absent or trace.
resting calcaneal stance
reverse Lasegue test
single leg stance
snuffbox tenderness
Speed test for biceps
stump (in case of amputee patient)
subtalar joint
subungual hematoma
talar tilt test
Thompson test
Tinel sign
toes are downgoing
too-many-toe sign (valgus deformity)
two-beat clonus
valgus/varus
varicose veins.
varus or valgus stress
wide-based gait
Yergason's test

NEUROLOGICAL:
Alert, awake, and oriented x3.
Alert, awake, and responsive.
anosmia
asterixis
Babinski.
Cerebellar function intact on finger-to-nose and rapid alternating movement
Cranial nerves II through XII grossly intact.
doll's eye reflex/sign
Dysmetria
extrapyramidal
facial droop
festinating gait
finger-to-nose.
flexors downgoing
Follows simple commands.
foot drop
gait and station
gaze / conjugate gaze / dysconjugate gaze
gaze preference
heel-to-shin.
homonymous field defect
horizontal nystagmus / vertical nystagmus / rotatory nystagmus
hypacusis
intention tremor
Moro's sign or reflex
motor impairment scale (MIS)
motor power
muscles of mastication
No cranial nerve deficit.
No focal deficits.
No focal weakness.
No headaches or seizures.
No history of convulsion, seizures, TIA or CVA.
noxious stimulation
oculocephalic reflex
oculocephalic maneuver
pronator drift
proprioception
rapid alternating movements
saccadic eye movements
sensory exam - pinprick
straight leg raising positive (negative) at 45 degrees
suck and grasp
tandem walk
two-point proprioception
vibratory sense intact
Withdraws in response to tactile and painful stimuli.

GENITOURINARY/GENITALIA:
balanitis
chancre
chordee
cremasteric reflex
circumcised phallus/penis
condyloma
epididymis
epididymis and cords are normal
genital warts
glans is normal
glans penis
meatus is orthotopic, patent and clear
no penile plaques or genital skin lesions
orchiectomy
perineum is normal
Peyronie disease
phallus
prepuce
priapism
scrotal swelling
scrotum
Tanner Developmental Scale
Tanner stage
testes descended bilaterally
testes have horizontal lie
testicular tumor
urethral groove
webbed penis

PELVIC:
adnexa negative for mass or tenderness
adnexa nontender
anterior lip of cervix
bimanual exam
bimanual rectovaginal exam
BUS negative. BUS = (Bartholin's, urethral, Skene's) glands
cervical motion tenderness
cervix dilated to approximately 2 cm, vertex, -1 station (values given as eg - actual as dictated)
cervix complete, 100% effaced, +2 station (values given as eg - actual as dictated)
cervix 3 cm dilated, 50% effaced, -2 station (values given as eg - actual as dictated)
cervix is long and closed
cervix is posterior and clean
cervix is smooth and normal in size
cervix was high
Chandelier sign
EGBUS - external genitalia (EG), Bartholin, urethral and Skene (BUS)
endometrial curetting
fibroids
GC and chlamydia culture
hysterectomy, oophorectomy
os is closed
pelvic floor
pelvic sidewalls are smooth
specimens for KOH and wet prep
supple pelvic floor
TAHBSO
uterine contour seems to be asymmetric
uterus is anteverted, anteflexed, and regular in contour
uterus is midposition
uterus normal size
uterus normal size, mobile, nontender
uterus retroverted
uterus was anteverted
uterus was sounded at
uterus, tubes, and ovaries
vaginal apex is normal
vagina and cervix without lesions or masses
vagina is pink, moist and rugose
vaginal vault

BREASTS:
no adenopathy
no dominant masses
no gynecomastia (IN CASE OF MALE PHY EXAM)
no nipple discharges or masses
no skin or nipple retractions
symmetrical

RECTAL:
anal wall
abscess
ampulla
black tarry stool
bright red blood per rectum
digital exam
Exam deferred.
fecal occult blood
fissures
fistula, condyloma
heme-positive stools
Hemoccult positive/negative
hemorrhoid
hemorrhoidal plexus
hemorrhoids
normal sphincter tone
prostate
prostate is smooth, nontender and without nodules or fluctuance
rectal ampulla
rectal vault
size, shape, and mobility of prostate gland
stool for guaiac

BACK/SPINE:
kyphoscoliosis
kyphosis
lordosis
No CVA tenderness.
paravertebral
scoliosis

SKIN:
ABCD - asymmetry, border, color and diameter
angel's kisses
blanch
branny desquamation
bullae (bulla - singular)
burrows
caput medusae
condyloma
defurfuration
dermatographism
desquamation
eczema.
epidermal avulsion
epidermolysis
exophytic lesion
flaking
follicular, horny-spined areas
folliculitis
goatee of face
honeycomb-crusted
hyperkeratotic areas
hyperpigmented plaques
inoculation points
icteric
infiltrative lesion
Janeway lesion
keloid
keratosis, actinic keratosis
Klippel-Trenaunay-Weber syndrome
lesions
lichenification
lymphangitic streaking
lytic lesion
maculopapular exanthem
molluscum
mottled, cyanotic
Muehrcke lines / bands / sign
neoplastic lesion
Nikolsky sign
no lesions, nodules or rashes
no onychomycosis
no streaking
normal color, turgor, and temperature
notable for tattoos
Osler node
papular, pustular rash
petechiae
pink and warm to touch
pitted keratolysis
pityriasis
port-wine stains
pruritic
purpura
purpuric lesions
rosacea
Rhus dermatitis
ruddy complexion
sandpapery rash
satellite lesion
scabies infestation
scale-like rash
scleredema
seborrheic dermatitis
skin cancer
skin tag
skin turgor
sloughing
spider angiomas.
spider nevi
stigmata of liver disease
stork bites
strawberry tongue
tenting
tyloma
ulceration, induration
unbroken and intact
urticaria
vascular streaking
verruca
vesicle
vesicular lesions
vesicular papules
vesiculation
warm and dry without rash
warm, dry, and well perfused
wart
wheal
wheal and flare reaction
xerosis
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HISTORY

The evolution of the transcription dates back to 1960s. The systems were designed to assist the manufacturing process. The first transcription that was developed in this process happens to be MRP (Medical Resource Planning) in the year 1975. This was followed by another advanced version namely MRP2 which is the acronym for Manufacturing Resource planning. None of them yielded the benefit of Medical Transcription.
However, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, voice recognition system (VRS) is increasingly being employed, with medical transcriptionists and or "correctionists" providing supplemental editorial services, although there are occasional instances where VRS fully replaces the MT. Natural language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (though MTs do).
In the past, these reportings consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department. Whenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy.
In recent years, things have changed considerably. Filing cabinets have given way to desktop computers connected to powerful servers where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Today we have speedy computers with many electronic references, and we use the Internet not only for web resources but also as our daily working platform. Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems (IS) staff to stream in voice and accomplish seamless data transfers through network interfaces. In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs), and are now utilizing software on them for dictation.
With all that has changed, some things have not. The conversion of spoken medical language to text is a craft that is difficult to learn and takes time to perfect. Some individuals have a "knack" for it; some will never get it. Technology can and does assist in many ways, but transcription still comes down to people. Even with the transition of MTs to editors for VRS documents, medical language interpretation skills will still be imperative for a quality report. MTs welcome this transition as an editor for VRS documents.

medical trascription notes

Medical transcription is the process where one accurately and swiftly transcribes medical records dictated by doctors and others, including history and physical reports, clinic notes, office notes, operative reports, consultation notes, discharge summaries, letters, psychiatric evaluations, laboratory reports, x-ray reports and pathology reports.

It involves receiving dictation by tape, digital system or voice file, and using earphones, a foot pedal for start-stop control and a word processing program. It sometimes includes the use of a printer and sometimes a modem. A variety of word-processing systems are used. It requires good listening and language skills, computer skills and knowledge of medical terms.