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