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Physical Examination Word List (General) Above-stated age Ambulate (d, tion, ing) Anxious Appropriate for age Appropriate for age Benign Combative Conscious Cooperative Cordial Cushingoid facies CVA tenderness Deferred Developmental milestones age appropriate Diaphoretic Disheveled Dizziness Dysphoric Emotional Fatigued Fingerstick Frail Grossly intact Healthy-appearing Hearty Hygiene (poor, good) Icterus Ill-appearing Immunizations up-to-date Infection (without evidence of, ) Jaundice Lethargic Mask-face-appearing Mild distress Mood changes No acute discomfort No acute distress No apparent distress Normal Not in any distress Older than stated age Oral hygiene good Oriented times 3 with proper affect Overweight Pale Pallor Abdomen Periorbital puffiness Pleasant Polypoid lesion Proper affect Psychological disturbances Psychosocially stable Pulse oximetry (Pulse Ox) Responsive Sad Thin Uncooperative Unhappy Unremarkable Up-to-date immunizations Upset Vertiginous dizziness Vertigo Vigorous Well-developed Well-healed Well-nourished Within normal limits Young appearing Younger than stated age Active bowel sounds Bladder Bowel sounds present Diffuse tenderness Enlarged liver Epigastric tenderness to palpation Flat Gravid (pregnant) Guarding (no) Hepatosplenomegaly (no) High pitched bowel sounds Infraumbilical scar Liver edge (no) Liver palpable Liver without enlargement Location (right lower quadrant tenderness, etc) Masses (no) Multiple striae Murphy sign (positive) Nondistended Nontender Normoactive bowel sounds Obese Obturator sign (positive) Organomegaly Palpable masses Positive bowel sounds Protuberant Psoas sign (positive) Pulsatile masses (no) Rebound (no) Rebound guarding (positive) Rotund Rushes (a bowel sound) Scaphoid Scar (midline, well-healed) Silver striae Spleen tip (no) Splenomegaly Supraumbilical region Without distention Back Breasts Costovertebral angle tenderness (no, negative) CVA tenderness (no) Degenerative disc disease Discogenic pain Dorsal kyphosis End plate convexities Facet joint pain Facet-related pain L3/L4 dermatoma decrease Lordosis Lower costal margin LS spine Lumbar No noted deformities Paraspinal muscle Range-of-motion Ribs Schober test Spinal tenderness (no) Thoracic spine Trapezius Axilla Axillae Axillary adenopathy Discrete mass Fibrocystic change Fibrotic consistency Mammogram Mass (with or without) Nipple discharge Nodularity Palpable mass Cardiovascular Heart Cor Chest 1/6 systolic murmur 2/6 systolic ejection murmur Aortic insufficiency murmur Apical rate Appreciable murmur Atrial contractions AV block Carotid bruits Constant split S1, S2 Controlled Diastolic blood pressure Discrete murmur Distant heart sounds Ectopic beat First degree AV block Grade 1/6 ejection murmur (at the upper sternal border) Grade 2 systolic ejection murmur Heart tones (normal) Incompetence (no evidence of) Irregular rhythm Irregular tachycardia JVD (elevated, or no) Mechanical valve sounds (normal) Mitral regurgitation No gallops No murmurs No rub (s) Normal S1 and S2 Occasional skipped beats Positive S4 Premature atrial contractions Premature atrial contractions Regular rate and rhythm Rhythmical Sinus rhythm (normal, regular) Sternal border Sternotomy scar T-wave inversion Tachycardia Tachycardia with summation gallop Tones (normal) Upper sternal border V5 through V6 unchanged Ventilatory excursions Ventricular enlargement Without S3, S4 See Lungs Cor Extremities Limb(s) Musculoskeletal Motor Gait See Cardiovascular 10-gram wire Abduction Accessory ossicle Achilles Achilles DTRs Achilles tendon Active extension Ambulate (d, ing, tion) Ankle jerk (absent, reflex) Ankle joint dorsiflexion Ankle reflexes Ankle-brachial indices were greater than 1 on both right and left Antalgic gait Arthroscopic surgery Avulsion of dorsal ligaments Babinski responses Ballottement Barlow maneuver (infant) Biceps Bony prominence Brachioradialis Carotid radial pulse Clonus (no) Clubbing Crepitation Crepitus Cross straight leg-raising (positive, negative) Cuboid area Cyanosis Decreased sensation Deep palpation Deep tendon reflexes (1+, 2+, etc) Deformity Discrete pulse Distal edema Dorsalis pedis pulse (palpable) Dorsiflexors Drawer (negative) Dry gangrene DTRs DTRs brisk Dystonic movement Edema (no, 2+, ) Effusion (mild) Exostosis Extension Femoral pulse Finger (PIP joint, MCP joint) Flexion Flexion/extension Foot evertors Full range-of-motion Fullness Gait (narrow-based, slow, steady) Gait is antalgic to the right with a foot drop Gait is steady without sway Gangrene Gastroc bilaterally Gastroc/soleus muscle complex Gibbous-like deformity Good foot care Good pulses Good strength Greater trochanters Grip (hand, weak) Hallux Hand grip Heel tap (positive) Heel-walk Hip click (no) Hips abduct fully Hoffmann test Hypoactive bilaterally Impingement syndrome Inferomedial Intention tremor Interphalangeal joint Intertriginous lesion Knee effusion Kyphosis Lachman’s (negative) Lateral aspect Lateral malleolus Lateral subluxation Leg edema Lesser tubercle (upper arm) Light touch Limp Lister tubercle (on the wrist) Manipulation MCL and LCL intact MCP joint (finger) Moccasin-type tinea Monofilament wire sensation Motor tic(s) MTP joint No clubbing, cyanosis, or edema Normal sensation ORIF (open reduction/internal fixation) – hip, Ortolani test (infant) Paronychia Passive extension Patella Patellar DTRs Patellar grind Patellofemoral grind Pedal edema Pedal pulses Perfusion Periarticular tenderness Peripheral adenopathy (no) Peripheral edema Peroneal groove Peroneal tendons Pes planus Pinprick PIP joint (finger) Pitting leg edema Pivot (negative) Planar arch Plantar fascial origin Plantar flexed Plantar flexion Plantar flexors Popliteal pulses Posterior tibial pulses Pressure ulcer (deep) Pretibial edema Pronation Radial pulse Range-of-motion Reflexes Reflexes (2+) Right dorsiflexion is 3+/5 Right extensor hallucis longus is 3+/5 Rotator cuff Sensation of light touch Sensory (grossly intact, decreased pinprick, etc) Sharp/dull light touch sensation Straight leg-raising (positive, negative) Streaking (no) Strength (5/5, 2/5, etc) Subtalar joint motion Suprapatellar pouch Synovitis (inflammation of the joints) Ten-gram wire Genitourinary (GU) Tendon jerks Tension signs (negative) Thompson test Tibial sag (negative) Tibialis anterior Tic (tics) Tinel’s Toe-walk Tone Tophus Trace edema Tremor (mild) Triceps Ulcerations Valgus deformities Varicosities Varus and valgus stressing Vibratory sensation Warm palms Wrist Pulses (carotid, carotid radial, discrete, dorsalis pedis, femoral, pedal popliteal, posterior tibial, radial) Anoperineal area Confirmatory External genitalia (normal) Foley catheter Guaiac negative Normal to inspection and palpation. Pelvic Prepubertal Rectocele Urethra Urethral meatus F Adnexa F Adnexa (palpable, nonpalpable) F Adnexal mass (no) F Atrophic vulva F Cervix F Corpus luteum F Cystocele F Cystocele (third degree) F EGBUS (External Genitalia, Bartholin's glands, Urethra & Skene's glands) F Endometrium F Enterocele F Follicle F Fornix (fornices) F Fullness F Gravid abdomen F Introital tissues Heart HEENT F Introitus (normal support) F Labia (swollen) F Ovaries normal in size and architecture F Pap normal F Pap smear F Pelvic support of the vaginal walls (excellent) F Per speculum F Prolapse F Rectovaginal F Scanty discharge F Secretory phase F Speculum F Subpubic angle (wide) F Uterus F Uterus (enlarged, asymmetric, nontender, globular) F Uterus (retroverted, anteverted, ) F Vagina (atrophic) F Vagina (no masses, no blood) F Vaginal apex F Vaginal mucosa (moist, healthy to inspection and palpation) F Vulva F Vulvar skin healthy M Epididymis M Inguinal canal M Inguinal hernia M Normal circumcised male M Normal descended testes M Normal uncircumcised male M Phallus M Scrotum M Testicles See Cardiovascular Acne Exudates (no) Facial hirsutism Frontal sinus Maxillary sinus Moist mucous membranes Tenderness (positive) Thyroid ophthalmopathy Upper and lower dentures in place Uvula and tongue without fasciculations Within normal limits E Auditory canals E Auricular lymph node E Bulging E Canals E Cerumen E Cone of light E E E E E E E E E E E E E E E E E E E E E E E E E E E E E Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Eardrums translucent Eardrums well visualized Eardrums with normal landmarks External canal (no blood) Fluid effusions Hearing aid Hearing decreased Injected Intratympanic fluid Landmarks (good) Light reflex (good) Mildly retracted Noninjected PE tubes patent Purulent discharge Redness Retracted (TMs) Right hypoplastic pinna Significant distortion TM TM has blood behind membrane TM with decreased mobility TM with possible hemotympanum TMs clear Tympanic membranes Tympanic membranes Tympanic membranes mildly retracted Tympanic membranes noted to be gray and mobile Without visible external auditory canal Anisocoria (right pupil 1-2 mm, left 2-3 mm) Anterior chambers (normal) Anterior segment Arcus senilis (bilaterally, positive ) Both pupils reactive Cataract Conjunctivae Cornea Cup-to-disc ratio Discs are flat and sharp EOMs intact (extraocular muscle) Esotropia Extraocular movements intact Extraocular muscles intact Foveal reflex Full visual fields bilaterally by confrontation Fundi with normal discs and vessels Fundus, Fundi, funduscopic, Icteric Myopia, myopic, Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey Ey H H H H H H H H H N N N N N N N N N N N N N N N N N N N N N N N N N Nystagmus Optic discs Papilledema (no) Peripheral hollows PERRULA Positive arcus senilis Proptosis Pupils equal, round, and reactive to light Pupils equally round and reactive to light and accommodation Red reflex (positive) Roth spots Sclerae clear Sharp discs bilaterally Tears Vision 20/20 Atraumatic Facial asymmetry Fontanelle (soft, anterior soft) Hair thinning NC/AT Normocephalic Normocephalic , atraumatic Temporal arteries nonindurated Thinning hair Blood in nostril Carotid (s) Chafing below the nares Clear discharge (positive) Congested Crusty rhinorrhea Deformity (no) Excoriated area on septum Fluid leakage (no) Frontal maxillary sinus cavities Hypertrophic inferior turbinates Increased pressure when leans forward Maxillary sinus cavity Nares Nares patent (bilaterally) Nares unobstructed Nasal discharge Nasal membranes Nasal pharynx (nasopharynx) Nostril (left, right) Purulent discharge Rhinorrhea Right maxillary sinus cavities Septal deviation Sinuses (nontender, ) Integument Lungs Chest Respiratory N Sinusitis N Without discharge N Yellow-to-green discharge noted T AE fold (aryepiglottic) T Aryepiglottic (A-E fold) T Cysts T Drainage T Erythema, erythematous T Hyperemic T Indirect mirror lanyngoscopy T Intraorally T No exudates T Nodes T Oral lesions T Oral mucosa T Oropharyngeal lesions (no) T Oropharynx clear T Palatal petechiae T Pharyngeal redness T Pharyngitis T Pharyngitis T Pharynx T Post nasopharynx drainage T Posterior oropharynx (dry) T Posterior pharynx T Pus pockets T Pyriform fossa T Red T Redundant soft palate T Smoker’s pharyngitis T Submandibular nodes T Tender nodes T Tonsils (enlarged) T Trachea midline T Uvula T Uvula was midline T Without erythema See Skin Accessory muscle breathing Aeration (good bilaterally) Air entry (good) Airway sounds Anterior chest Anterior/posterior diameter Bibasilar rales Chest wall tenderness (no) Clear Clear AP and laterally Clear to A&P Motor Neck Clear to auscultation and percussion Clear to auscultation bilaterally Coarse rhonchi Coarse, pressed breath sounds Contusion (no) Crackle Decreased breath sounds Diffuse wheezes Diminished sounds Egophony (no) Expands adequately Expiratory wheezes Fine basilar rales Good air entry Hyperresonant to percussion Inspiratory crackle Labored breathing Lateral aspect Lung fields (clear) No rales, wheezes, or rhonchi No retractions O2 sat (Oxygen saturation) Occasional rhonchi Peritoneal catheter Pressed breath sounds Rales (bilateral) Respirations symmetrical Respiratory expansion (good) Symmetric Tachypnea Tactile fremitus Thrill (sound) Trauma (no) Upper airway sounds Velcro rales See Extremities Adenopathy (with or without) Bruit(s) Carotid bruit (no) Carotid pulses Cervical adenopathy Cervical adenopathy in cervical chain Cervical chain Cervical lymphadenopathy (no) Cervical spine Decreased range-of-motion globally (mild-to-moderate) Enlarged thyroid Firm thyroid Flat neck veins Neurologic (al) Rectal Respiratory Generalized tenderness Glands Goiter Hepatojugular reflux JVD Low-lying thyroid Lymph nodes (no enlargement) Lymphadenopathy (with or without) No point tenderness Nodularity (no, without) Nontender Occipital movement (good, anterior) Range-of-motion (full, limited, good) Submandibular nodes (large) Supple Supraclavicular adenopathy Symmetric Thyroid irregularity (no) Thyroid lobe (full) Thyroid nodule Thyromegaly (no) Bilateral 6 nerve palsy CNS developmental milestones age appropriate Coordination Cranial nerves II-XII are intact Dystonic movement Finger-to-finger Finger-to-nose Focal deficits (no) Nonfocal Physiologic Fleshy polyp on the left posterolateral wall. Good sphincter tone Guaiac negative brown stool Heme negative Hemoccult negative stool Left inferior lobe apical nodule Masses (no) Nontender prostate Normal sphincter tone Normal tone Polyp Positive nontender external hemorrhoids Prostate (smooth, small, soft) Rectocele Sessile polyp Stool heme negative Vault (stool in, rectal) See Lungs Sensory Skin Integument Teeth Vascular exam Vital signs See Extremities Acne Acneform lesions Actinic keratosis (keratoses) Asteatotic eczema Bruise, bruises, bruised Diffuse erythema Eczema Fluctuant Hematomas Hydrated Hyperpigmented rash Intertriginous lesion Keloid formation Keratotic lesion Macular rash Maculopapular lesion Mottled rash Petechia Pigmented lesion Pink Pruritic rash Purpura Raised lesion Rash (red, macular) Skin tags Turgor (good) Vasculitic lesions Verruca vulgaris Violaceous maculopapular lesion Warm and dry Wart Wart-like Without lesions Dentures (upper, lower) No trauma Dopplerable left femoral pulse Dorsalis pedis pulse Lower extremity pulses all palpable Noted bruit Popliteal pulse Pulses in upper extremities equal and symmetrical bilaterally Alert and oriented times 3 Blood pressure Blood pressure (sitting, standing) Blood pressure with a manual cuff Dizziness Febrile/afebrile Heart rate Height O2 saturation Pulse (regular) Pulse Ox Pulse oximetry Pulse rate (##/minute) Respirations Respiratory rate (regular, irregular, labored, not labored) Saturation Stable Temperature (normal) Weight
