Tersm used in Physical Examination
General:
Apgar score (newborn)
Apgar score was 8 at one minute and 9 at five minutes
arousable
awake, alert and oriented
awake, alert and oriented X 3 (times 1, 2 or 3)
cachectic/cachexia
Cheyne-Stokes breathing
comatose
cushingoid
diaphoretic
dyspnea
dyspneic
lethargic
mask facies, masklike facies
no acute distress (NAD)
obese
obtunded
oriented to person, place and time
orthostatic changes
pallor
tachypnea
tachypneic
unresponsive
well-developed, well-nourished
Vital signs:
Blood pressure: 120/80 mm Hg (millimeters of mercury)
Pulse rate: 80 (per minute) (see "Cardiac Exam" below)
Respiratory rate: 18 (per minute), labored/unlabored
Temperature: 98.6 degrees F. (sometimes T-max=temperature maximum)
afebrile/febrile
Skin:
abrasions complexion - flushed/pale/pallor/ruddy decubital decubitus ulcers (NOT decubiti) ecchymosis, pl. ecchymoses eczema eczematoid eczematous edema edematous erythema erythematous eschar herpes simplex herpes zoster herpetic lesion lichenoid edema maculopapules maculopapular rash pale pallor petechiae plethoric psoriasis/psoriatic purpura rash, petechiae, or purpura scleredema spider angiomata stigmata of liver disease tenting (skin/tissue) turgor
Head, eyes, ears, nose and throat: (HEENT) Head:
atraumatic
atraumatic, normocephalic (AT/NC) Battle's sign (cap the "B" - named for Dr. William H. Battle) flattening of the (left/right) nasolabial fold fontanel (infant exam) macrocephaly/macrocephalic megacepahaly/megacephalic microcephaly/microcephalic nasolabial fold normocephalic normocephalic, atraumatic (NC/AT) raccoon eyes
Eyes:
Pupils equal, round, and reactive to light and accommodation. (PERRLA) Pupils equal, round, and reactive to light. (PERRL) Pupils equal and reactive to light. (PERL) (above may be dictated as PURL or PURL-LAH) Pupils (fixed/dilated/pinpoint)
anicteric arcus senilis arterial pulsation Battle's sign best-corrected visual acuity cataract conjunctivae pink, not injected, clear, normal, muddy, no pallor cornea clear/cloudy corneal reflex intact disk/disc margins well-delineated disks/discs sharp enucleated extraocular movements (EOM) (may be dictated EE-OHM) extraocular movements intact (EOMI) (may be dictated EE-OH-MEE) fundi well-visualized/not well-visualized/not examined funduscopic examination, funduscopy homonymous hemianopsia H or E (hemorrhage or exudate) iridectomy isocoria/isocoric (meaning the pupils are equal bilaterally) lenticular opacification macular degeneration nystagmus opacification opacified papilledema ptosis (pronounced TOH-SIS) raccoon rapid eye movements (REM) red reflex retinopathy sclerae anicteric/icteric slit-lamp examination strabismus visual acuity
Ears:
auditory canal
cerumen injected myringotomy tubes poor light reflex TMs (tympanic membranes) tympanic membranes intact - red/bulging/dull Nose:
boggy turbinates congested flattening of the nasolabial fold nasolabial fold inferior turbinate polyps septal deviation sinus turbinate/turbinate hypertrophy Mouth and throat: (oral examination)
aphthae aphthous ulcers bifid bifid uvula buccal mucosa cleft palate dentition edentulous erythema exudate hard palate mucous membranes moist/dry palate pharynx protruded tongue midline soft palate temporomandibular joint thrush tongue well-papillated uvula moves on phonation uvula and tongue midline
Neck examination:
carotids 2+ and equal bilaterally
carotid bruit
cervical adenopathy goiter hepatojugular reflux (HJR) jugular venous distention (JVD) lymph nodes not palpable/palpable, hard, immobile, fixed, freely mobile lymphadenopathy multinodular goiter pharynx shotty lymph nodes [NOT shoddy] stridor supple thyroid not palpable thyromegaly venous distention at 45 degrees
Chest/Breast:
AP diameter (anterior-posterior diameter)
areola atrophic axilla ( No adenopathy or lymphadenopathy, no nodes felt.) breasts atrophic (older women) gynecomastia (men) mastectomy no nipple discharge no lumps or masses permanent pacemaker status post mastectomy sternum sternotomy scar Tanner thoracic thorax
Lungs:
accessory muscles of respiration
adventitious sounds AP diameter normal/increased atelectasis clear to auscultation and percussion (A and P/P and A) Clear to auscultation without flaring, grunting or retraction. coarse rales costophrenic angles crackles/crackling crepitant rales crepitation crepitus Cheyne-Stokes breathing dullness to percussion dyspnea dyspnea on exertion E to A changes (egophony) [patient says "EEEE" MD hears "AAAAA"] egophony end-expiratory wheeze expiratory time normal/prolonged expiratory wheeze expiratory wheeze 1+, 2+, etc. forced expiratory time hyperresonant hyperventilation hypoventilation moist rales pleural rub rales rhonchi rub wheeze
Cardiac Examination:
A2 louder than P2
aortic click aortic regurgitation apical systolic murmur arrhythmias asystole atrial fibrillation (often dictated Ay-Fib or AF) atrial flutter bradycardia cardiomegaly click diastolic murmur first heart sound (S1) first and second heart sounds normal; no third or fourth heart sound fourth heart sound ejection murmur ejection systolic murmur gallop grade 1/6, 2/6, 3/6, 4/6, 5/6* grade I, grade II, grade III, grade IV, grade V, grade VI* heart sound heave holosystolic murmur intercostal space irregularly irregular knock MAT (multifocal atrial tachycardia) midclavicular line mitral valve prolapse mitral regurgitation multifocal atrial tachycardia (MAT) murmur murmur radiating to the axilla or neck normal sinus rhythm (NSR) P2 louder than A2 parasternal border pericardial knock physiologically split PMI - point of maximum impulse point of maximum impulse (PMI) in fifth intercostal space premature ventricular contractions (PVC) prosthetic click/sound PVC - premature ventricular contractions regular sinus rhythm (RSR) rapid ventricular response rub S1, S2, S3, S4 S1 equals S2 S1 and S2 normal, no S3 or S4 S3 gallop second heart sound (S2) supraventricular tachycardia (SVT) systolic ejection murmur tachycardia third heart sound (S3) thrill tricuspid regurgitation ventricular fibrillation (often dictated Vee-Fib) ventricular tachycardia (often dictated Vee-Tak)
Abdominal examination:
ascites
ballottable bowel sounds normal (normoactive, hyperactive, hypoactive, high-pitched, inaudible, tympanitic, decreased, diminished) costovertebral angle tenderness (CVA tenderness/CVAT)[back exam] distended, nondistended exogenous obesity fluid wave guarding liver and spleen not palpable 1-2 fingerbreadths below right costal margin hepatomegaly hepatosplenomegaly liver, spleen and kidneys not palpable/not felt spleen enlarged/not enlarged/not felt tender, nontender McBurney's point (location to test for appendix) morbid obesity Murphy's sign obese organomegaly palpable, nonpalpable protuberant rebound rebound tenderness scaphoid scars of previous surgery tender, nontender visceromegaly
Landmarks: axillary line costophrenic angle costovertebral angle epigastric
inguinal left costal margin left lower quadrant left upper quadrant ligament of Treitz McBurney's point midclavicular line Murphy's point paramedian parasternal border right lower quadrant right upper quadrant right costal margin subclavicular suprapubic area symphysis pubis xiphoid to pubis xiphoid process
Back:
C-spine
cervical spine costovertebral angle tenderness (CVA tenderness/CVAT) dorsal spine kyphosis kyphoscoliosis lumbar lumbosacral palpation and percussion paravertebral point tenderness radiation referred pain sacrum sciatica scoliosis Straight without dimples
Extremities:
above-knee amputation (AKA)
arc of motion below-knee amputation (BKA) CCE (cyanosis, clubbing or edema) calf tenderness capillary refill claudication clubbing cords cyanosis decubitus ulcer Doppler dorsalis pedis pulses DP/PT - dorsalis pedis, posterior tibial (pulses) edema edema 1+ (2+, 3+) edematous femoral pulse full range of motion hip click (baby examination) Heberden's nodes of osteoarthritis Homans' sign Lachman's sign (often pronounced "lock-man's") mottling pedal edema peripheral pulses pitting edema popliteal pulse posterior tibial pulse (PT) pulses 2+ and equal bilaterally range of motion reflexes positive grasp and suck varicose veins varicosities
Rectal examination: ampulla black tarry stool bright red blood per rectum guaiac-negative/positive heme-positive (negative) Hemoccult positive/negative hemorrhoid - internal/external hemorrhoidal plexus maroon-colored mass prostate prostate hard and nodular prostate firm and 2+ prostate not enlarged rectal ampulla rectal examination refused by patient rectal vault stool guaiac-negative/positive tarry stool vault empty
Genitalia/Pelvic: adnexa Bartholin's gland BUS (Bartholin's, urethral, Skene's) glands chandelier sign chordee circumcised epididymis (pl. epididymides) epididymitis glans glans clitoridis glans penis hernia (direct/indirect/sliding) herpes/herpetic lesions/herpes zoster herpes simplex virus (HSV) labia labia majora labia minora lochia menarche normal for age normal male/female genitalia normal postmenopausal parous penis perineal [NOT peroneal] perineum [NOT peritoneum] phimosis scrotum Skene's gland status post orchiectoamy Tanner Developmental Scale Tanner growth chart Tanner stage I (II, III, etc.) testes/testicles descended testis (singular) uncircumcised undescended testicle uterus uterus anteverted / retroverted uterus six weeks' size vagina vaginal discharge venereal warts verruca acuminatum (venereal wart) vulva
Neurological examination:
ankle jerks aphagia aphasia asymmetry ataxia ataxic gait Babinski sign (negative/positive/withdrawal/equivocal) Bell's palsy cerebellar confrontation coordination corneal reflex/response cranial nerves II through XII grossly intact deep tendon reflexes doll's eye reflex/sign dysarthria / dysarthric extrapyramidal face symmetric facial droop facial strength and sensation festinating gait finger-to-nose flattening of the nasolabial fold flexors downgoing foot drop gag reflex gait - ataxic, athetotic, broad-based, dropfoot, dystonic, equine, festinating gait and station gaze preference heel-to-knee-to-shin test hemiparesis hemiplegia homonymous field defect homonymous hemianopsia intention tremor knee jerk light touch meningeal sign Moro's sign or reflex motor power motor or sensory deficits muscles of mastication no meningeal sign nonfocal noxious stimulation nystagmus oculocephalic maneuver paresthesias pinprick plantar flexion plantar reflexes (downgoing/upgoing/equivocal/withdrawal) plantars 2+ and equal bilaterally position posturing proprioception rapid alternating movements Romberg's sign sensorimotor deficit suck and grasp speech (fluent, dysarthric) station strength and sensation intact straight leg raising positive (negative) at 45 degrees tandem walk temperature sense titubation (head or trunk tremor) tongue protrudes in the midline vibratory sense visual field visual fields are full withdrawal (on plantar or Babinski testing)
Mental Status:
affect affective alert and oriented x 3 alert and oriented to person, place and time Axis I: Clinical disorders, syndromes and/or other areas of concern Axis II: Personality disorders and mental retardation Axis III: Medical conditions (which may impact emotions) Axis IV: Psychosocial stressors (death, divorce, loss of job, etc.) Axis V: Global assessment of functioning. dangerous ideation delusions depression flat affect flight of ideas grandiose/grandiosity hallucinations homicidal ideation ideas of reference ideation insight and judgment memory - immediate/recent and remote pressured speech/pressure of speech psychomotor agitation/retardation psychosocial stressors social judgment stressors suicidal ideation/suicidality tangential/tangentiality
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