physical examination terms

8/22/2019 Physical Examination Terms

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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


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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


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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

agnathiaallergic salutealopeciaallergic shiners


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alopecia notedanicteric scleraeanisocoria

anterior tonsillar pillars are redaphthae

aphthous ulcers

arcus senilisAV nickingBattle's signbest-corrected visual acuitybifid

bifid uvula

bifocals (wears bifocals)boggy turbinates

buccal mucosabulbar conjunctivaecataractscleft palate

cobblestoningconjunctivae pink

conjunctivitiscornea clear/cloudy

corneal reflex intact

Cowden disease


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crowded oropharynxDennie-Morgan lines /Dennie-Morgan fold

dental cariesdental hygienedentitiondenturesdeviation of mouthdisk margins well-delineateddisks sharpdysconjugate gazeears have mild cerumen or no cerumenedentulouseffusionelongation of soft palate

endotracheal tubeenucleated

EOMIEOMS full. (EOMS can mean either extraocular movements or extraocularmuscles)ET (endotracheal) tube in place

external auditory canalextraocular movements intactextraocular muscles intactfacial droop


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facial sensation is intactflattening of the nasolabial fold

floor of mouth is nontenderfontanel (infant exam)funduscopic examgag reflexgingivagingival hyperplasiaglaucomagood cone of lightGuerin fracturehairy leukoplakiahalitosis

hard palate / soft palate

has pterygium on the eyehead traumahelix of ear is tender to touchhomonymous hemianopsiahypopharynx and larynx are normal

impacted molarsisocoria or isocoric

Le Fort fractureLe Fort I fracture


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Le Fort II fractureLe Fort III fracturelenticular opacification

leonine faciesLudwig anginamacrocephaly / microcephalymacular degeneration

Mallampati grade (pharynx is Mallampati grade 3)mandibular hypoplasiamastoid air cell tendernessmaxillary, ethmoid, frontalmicrognathiamidface and mandible are stablemoist mucous membranes

mucosa is boggymucosal pallormucositismyringotomy tubes

nares, patentnasal bridge

nasal flaringnasal mucosa edematous or nonedematousnasal passages are crowdednasal prongs


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nasolabial fold flatteningnasopharyngeal trumpet

NC/ATNG tube or nasogastric tubeno epistaxis or epistaxis seenno exudates, plaques or lesionsno facial linesno field cut to gross confrontationno hemotympanumno papilledema, AV nicking, hemorrhages or exudates notedno scleral icterusno traction on the pinnanormocephalic and atraumaticOP (oropharynx) clear

oral exam shows slight crowdingorbital, periorbitaloropharynx is clear.oropharynx is noninjected / oropharynx is injectedpalatal movements diminished

periodontal diseasePERRLPERRLApharyngeal hyperemia


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pharynx is crowdedpharynx pink and moistphonation problems

Pierre Robin syndromepinnaplethoric faciespoor light reflexposterior pharynx without injectionpre or postauricular nodespuffing of eyelidspunctate exudates on tonsilspupils are equal, round, and reactive to light and accommodationraccoon eyesrapid eye movements (REM)

red reflexRinne test

sclerae and conjunctivae are normalseptal deviation

sinuses are nontender to percussionsinuses

slit-lamp examination

sluggish pupilssore throatstrabismus


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symmetrical vocal cord motiontemporomandibular joint

throat is clearthrush

TMs shiny and clearTM has a slight bulge and diffusion of cone of lighttongue congestiontongue is drytongue well-papillated

tonsillar hypertrophytonsils (tonsils are 3+ bilaterally)trichilemmomatrismus (no trismus)tympanic membranes

uvulauvula is nonedematousuvula moves on phonationvermilion bordervisual acuity is _____ (dictated value, usually 20/20)

visual field testingwax impactionWeber testNECK:anterior cervical lymphadenopathy


11/21

bilateral bruits conducted from the aortic areas to both carotids.Brudzinski signcarotids are +2/4carotids are fullelevated JVP up to the angle of the jaw

free of masses.goiterhepatojugular reflux or HJR (abbrev)JVD at 30 degrees, head up position.meningeal irritationmeningeal signsmeningismusneck 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 notraisedno JVD elevation.no lymphadenopathy or thyromegaly.no nodularity.no thyroid enlargement.nuchal rigiditynuchal spasmshotty lymph nodes (sounds "shoddy" but its shotty)trachea centraltrachea midline

tender nodesvenous distention at 45 degreesHEART OR CARDIOVASCULAR:

A2 louder than P2apical impulseapical murmuraudible murmursgrade 1/6 or 2/6 or 3/6 systolic murmur.irregularly irregular rhythm

loud P2loud S3 gallopno ectopyno extra heart soundsno friction rubno heave or thrillno MR, no AIno precordial heave


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no S3 or S4 appreciatedpericardial knockPMI 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/soundRegular rate and rhythm.RRR.RSRS1 normal intensity, S2 single.S1, S2, S3, S4.S2 snapping sound with mild mitral insufficiencysoft 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 chestexpansion was symmetricmidline sternotomy scarpigeon chest

LUNGS OR PULMONARY:accessory muscles of respiration

adventitious soundscostophrenic anglescrackles, wheezes, rhonchi.crepitant ralesCTA (clear to auscultation)diminished breath sounds.E to A changesequal breath soundsgood bilateral air entry.good breath sounds.good air exchange

hyperresonantincreased AP diameterinspiratory, expiratory.lung fields.Lungs are clear to A&P.Lungs are clear to auscultation and percussion.no retractionnormal AP diameter


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pleural rubunlabored breathingvesicular breath sounds

ABDOMEN:

all 4 quadrantsappendectomy scarascitesballottableBowel sounds are active.cesarean section/hysterectomy scar seen.diffuse direct tendernessepigastric bruitfluid wavehyperactive bowel sounds.hypoactive bowel sounds.liver and spleen not palpable.liver is palpableMcBurney's pointMurphy's signNo guarding, rebound, hepatosplenomegaly.No masses. No hernias.No organomegaly or masses.Normoactive bowel sounds.Obese, bulky.PEG tube in place.peristalsisPositive bowel sounds.

protuberant.renal anglesscaphoid abdomenscars from previous surgery seenscars of surgery.soft, flat, nontender, nondistendedstoma is patentEXTREMITIES OR MUSCULOSKELETAL:1+ or 2+ edema.above-knee amputation

anatomic snuffboxankle dorsiflexionankle edema.anterior drawer signApley grind testApley's testarc of motionballotable patella


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balls of feetbeats of clonusbelow-knee amputationbrachial pulses are 1-2+bunion

calcaneal cuboidcalf tendernesscapillary refillCCE (cyanosis, clubbing or edema)Charcot foot.claudicationclonusclubfoot."clunk" test for tib-fibCram testdependent edemaDJD (degenerative joint disease)Dorsalis pedis and posterior tibial pulses.DP and PT pulses.drop-arm test for rotator cuff tearDTRs are 2+.DTRs are brisk.DTRs are symmetric.DTRs are trace.flexion contractureflexor digitorumfootdropfunctional hallux limitus

genu valgum/genu varumgolfer's elbow testgood joint range of motion without bony deformitiesgravity drawer testgrip is fullhallux valgusHawkins test (Hawkins impingement sign)Heberden's nodes of osteoarthritiship click (infant examination)Homans signHoover sign / test

LachmanLudington testMcMurray's testMild pedal edema / trace pedal edema.milking the kneeMoves all 4 extremities well.Mulder signNeer test (Neer impingement sign)


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neutral calcaneal stanceno bony or joint abnormalitiesNo calf tenderness.No cellulitis.No cyanosis, clubbing or edema.

No lymphedema.patella apprehension testperipheral circulationperipheral pulses are intactPhalen testpitting edema.pivot shiftplantar flexionpoststatic dyskinesiaposterior drawer signposterior sag signradial pulsereflexes are 2+ or absent or trace.resting calcaneal stancereverse Lasegue testsingle leg stancesnuffbox tendernessSpeed test for bicepsstump (in case of amputee patient)subtalar jointsubungual hematomatalar tilt testThompson test

Tinel signtoes are downgoingtoo-many-toe sign (valgus deformity)two-beat clonusvalgus/varusvaricose veins.varus or valgus stresswide-based gaitYergason's test

NEUROLOGICAL:

Alert, awake, and oriented x3.Alert, awake, and responsive.anosmiaasterixisBabinski.Cerebellar function intact on finger-to-nose and rapid alternating movementCranial nerves II through XII grossly intact.doll's eye reflex/sign


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Dysmetriaextrapyramidalfacial droopfestinating gaitfinger-to-nose.

flexors downgoingFollows simple commands.foot dropgait and stationgaze / conjugate gaze / dysconjugate gazegaze preferenceheel-to-shin.homonymous field defecthorizontal nystagmus / vertical nystagmus / rotatory nystagmushypacusisintention tremorMoro's sign or reflexmotor impairment scale (MIS)motor powermuscles of masticationNo cranial nerve deficit.No focal deficits.No focal weakness.No headaches or seizures.No history of convulsion, seizures, TIA or CVA.noxious stimulationoculocephalic reflexoculocephalic maneuver

pronator driftproprioceptionrapid alternating movementssaccadic eye movementssensory exam - pinprickstraight leg raising positive (negative) at 45 degreessuck and grasptandem walktwo-point proprioceptionvibratory sense intactWithdraws in response to tactile and painful stimuli.

GENITOURINARY/GENITALIA:balanitischancrechordeecremasteric reflexcircumcised phallus/peniscondyloma


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epididymisepididymis and cords are normalgenital wartsglans is normalglans penis

meatus is orthotopic, patent and clearno penile plaques or genital skin lesionsorchiectomyperineum is normalPeyronie diseasephallusprepucepriapismscrotal swellingscrotumTanner Developmental ScaleTanner stagetestes descended bilaterallytestes have horizontal lietesticular tumorurethral groovewebbed penisPELVIC:adnexa negative for mass or tendernessadnexa nontenderanterior lip of cervixbimanual exam

bimanual rectovaginal examBUS negative. BUS = (Bartholin's, urethral, Skene's) glandscervical motion tendernesscervix 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 asdictated)cervix 3 cm dilated, 50% effaced, -2 station (values given as eg - actual asdictated)cervix is long and closedcervix is posterior and clean

cervix is smooth and normal in sizecervix was highChandelier signEGBUS - external genitalia (EG), Bartholin, urethral and Skene (BUS)endometrial curettingfibroidsGC and chlamydia culturehysterectomy, oophorectomy


18/21

os is closedpelvic floorpelvic sidewalls are smoothspecimens for KOH and wet prepsupple pelvic floor

TAHBSOuterine contour seems to be asymmetricuterus is anteverted, anteflexed, and regular in contouruterus is midpositionuterus normal sizeuterus normal size, mobile, nontenderuterus retroverteduterus was anteverteduterus was sounded atuterus, tubes, and ovariesvaginal apex is normalvagina and cervix without lesions or massesvagina is pink, moist and rugosevaginal vaultBREASTS:no adenopathyno dominant massesno gynecomastia (IN CASE OF MALE PHY EXAM)no nipple discharges or massesno skin or nipple retractionssymmetricalRECTAL:anal wallabscessampullablack tarry stoolbright red blood per rectumdigital examExam deferred.fecal occult bloodfissuresfistula, condyloma

heme-positive stoolsHemoccult positive/negativehemorrhoidhemorrhoidal plexushemorrhoidsnormal sphincter toneprostateprostate is smooth, nontender and without nodules or fluctuance


19/21

rectal ampullarectal vaultsize, shape, and mobility of prostate glandstool for guaiacBACK/SPINE:kyphoscoliosiskyphosislordosisNo CVA tenderness.paravertebralscoliosisSKIN:ABCD - asymmetry, border, color and diameterangel's kissesblanchbranny desquamationbullae (bulla - singular)burrowscaput medusaecondylomadefurfurationdermatographismdesquamationeczema.epidermal avulsionepidermolysis

exophytic lesionflakingfollicular, horny-spined areasfolliculitisgoatee of facehoneycomb-crustedhyperkeratotic areashyperpigmented plaquesinoculation pointsictericinfiltrative lesion

Janeway lesionkeloidkeratosis, actinic keratosisKlippel-Trenaunay-Weber syndromelesionslichenificationlymphangitic streakinglytic lesion


20/21

maculopapular exanthemmolluscummottled, cyanoticMuehrcke lines / bands / signneoplastic lesion

Nikolsky signno lesions, nodules or rashesno onychomycosisno streakingnormal color, turgor, and temperaturenotable for tattoosOsler nodepapular, pustular rashpetechiaepink and warm to touchpitted keratolysispityriasisport-wine stainspruriticpurpurapurpuric lesionsrosaceaRhus dermatitisruddy complexionsandpapery rashsatellite lesionscabies infestationscale-like rash

scleredemaseborrheic dermatitisskin cancerskin tagskin turgorsloughingspider angiomas.spider nevistigmata of liver diseasestork bitesstrawberry tongue

tentingtylomaulceration, indurationunbroken and intacturticariavascular streakingverrucavesicle


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vesicular lesionsvesicular papulesvesiculationwarm and dry without rashwarm, dry, and well perfused

wartwhealwheal and flare reactionxerosis

physical examination terms

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