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Physical Examination Terms
Numerals: The use of arabic versus Roman numerals is often a matter of style and personal choice. Some references such as AAMT Book of Style recommend the use of arabic numerals in all cases, others recommend use of Roman numerals except when used as a mathematical expression, and other medical references always list murmurs with Roman numerals. Additionally, there are many conflicting resources with regard to whether "grade" should be capitalized or not, more suggesting not.
Apostrophes: Recent trend is to drop apostrophes as in Gram stain or Battle sign.
Ask your client or service manager for their preference as to numerals and apostrophes.
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
- 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
- megacephaly/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
Throat/mouth
- 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
- 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)
- 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
- 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)
Back/Spine
- 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
Abdominal
- 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
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
- varicose veins
- varicosities
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 orchiectomy
- 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
Rectal
- 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
Neurologic
- 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
- 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
Reference Books
- Mosby's Physical Exam Handbook
- Pocket Guide to Physical Exam & History Taking
- Writing S.O.A.P. Notes
- AAMT Book of Style
- Medical Keyboarding, Typing, & Transcribing: Techniques & Procedures
- Medical Phrase Index