Medical homework help...?

Question

I am studying to be a medical transcriptionist and am stuck on a particular paragraph. The dictator has a very heavy accent and this is what it sounds like he has dictated. The lines indicate the words I cannot figure out.

Physical assessment revealed there was no _____ [s/l unlocal] rigidity. Pharynx was clear. Heart rate regular. Abdomen was soft. Rectal exam deleted. Lower extremities free of any significant _______ [s/l pretivity] edema. There was bilaterally negative Homans.

Thanks!

Answer 1

Believe or not, it would help to know what the presenting complaint was -- doctors often tailor their physical exam to rule in or rule out diagnoses.

For example, in the neck region, the doctor may pay particular attention to the presence/absence of neck stiffness (nuchal rigidity) if he/she is suspecting meningitis, but in someone with suspected pulmonary edema, he/she may look for jugular vein distention instead.

Anyway, without more information, my guesses for your blanks are:

1. __nuchal__   rigidity

2. __pitting__   edema

Also, rectal exams are often "deferred", but who knows, maybe your doc actually deleted a rectal exam....

Good luck!