Physical Exam terms

Update: Feb 17th, 2011

A large part of medical transcription consists of physical exams.  Physicians become so accustomed to rattling off physical exam terms that the words often run together or are even left out.  Physical exams are typically conducted in system-by-system, head-to-toe order.  This list of physical examination terms may be helpful in filing in one of those left out or runtogether words.

 

General appearance:

A&O x3 -alert and oriented times 3

agitated

ambulatory

cachectic

Cheyne-Stokes breathing

chronological age (younger/older than)

comatose

conscious

cushingoid

diaphoretic

disheveled

elderly, frail

engages with the examiner without difficulty

engaging appropriately

language disturbance

intubated and sedated

lucid and follows commands

lying in semi-Fowler position

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 

WDWN (well-developed, well-nourished)

wearing glasses

well hydrated

Head, eyes, ears, nost throat:

afferent pupillary defect

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

depressed nasal bridge

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)

frontal bossing

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

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

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- pupils are equal, round and reactive to light

PERRLA – pupils are equal, round and reactive to light and accomodation

pharyngeal hyperemia

pharynx is crowded

pharynx pink and moist

phonation problems

Pierre Robin syndrome

pinna

plethoric facies

poor light reflex

posterior pharynx is without thrush

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

tongue was protruding with some swelling and akinesia

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

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  

trachea central

trachea midline

tender nodes

venous distention at 45 degrees

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

no adenopathy

no dominant masses

no gynecomastia

no nipple discharges or masses

no skin or nipple retractions

pigeon chest

symmetrical

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

colostomy is in place

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

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

bilateral symmetrical muscular atrophy

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.

downgoing reponse to plantar stiumlation

DP and PT pulses.

drop-arm test for rotator cuff tear

DTRs are 2+.

DTRs are brisk.

DTRs are symmetric.

DTRs are trace.

femoral stretch test

flexion contracture

flexor digitorum

footdrop

functional hallux limitus

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 – dynamic Hoffmans 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)

no bony or joint abnormalities

No calf tenderness.

No cellulitis.

No clonus noted.

No cyanosis, clubbing or edema.

No gross deformities.

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

prone knee bend test

radial pulse

reflexes are 2+ or absent or trace.

reverse Lasegue test

single leg stance

snuffbox tenderness

Speed test for biceps

straight leg test

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: 

balanitis

chancre

chordee

cremasteric reflex

circumcised phallus/penis

condyloma

epididymis

epididymis and cords are normal

Foley to gravity

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

Pelvis:

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

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

Spine: 

destroscoliosis

kyphoscoliosis

kyphosis

levoscoliosis

lordosis

No CVA tenderness.

paraspinal

paravertebral

scoliosis

TLSO brace

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

 

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