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Physical Examination Word List(General)Above-stated ageAmbulate (d, tion, ing)AnxiousAppropriate for ageAppropriate for age Benign Combative Conscious Cooperative Cordial Cushingoid facies CVA tendernessDeferredDevelopmental milestones age appropriateDiaphoreticDisheveled DizzinessDysphoricEmotionalFatiguedFingerstick FrailGrossly intact Healthy-appearingHearty Hygiene (poor, good)IcterusIll-appearing Immunizations up-to-date Infection (without evidence of, )Jaundice Lethargic Mask-face-appearing Mild distressMood changes No acute discomfortNo acute distress No apparent distressNormal Not in any distressOlder than stated ageOral hygiene good Oriented times 3 with proper affectOverweightPalePallorPeriorbital puffinessPleasantPolypoid lesionProper affectPsychological disturbancesPsychosocially stable Pulse oximetry (Pulse Ox)Responsive SadThinUncooperative UnhappyUnremarkable Up-to-date immunizationsUpsetVertiginous dizzinessVertigoVigorous Well-developed Well-healedWell-nourished Within normal limits Young appearingYounger than stated ageAbdomen Active bowel sounds Bladder Bowel sounds present Diffuse tenderness Enlarged liverEpigastric tenderness to palpation Flat Gravid (pregnant)Guarding (no)Hepatosplenomegaly (no)High pitched bowel sounds Infraumbilical scarLiver edge (no)Liver palpable Liver without enlargementLocation (right lower quadrant tenderness, etc)Masses (no)Multiple striae Murphy sign (positive)Nondistended NontenderNormoactive bowel soundsObeseObturator sign (positive)Organomegaly Palpable masses Positive bowel soundsProtuberant 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 regionWithout distention Back Costovertebral angle tenderness (no, negative)CVA tenderness (no)Degenerative disc disease Discogenic painDorsal kyphosisEnd plate convexitiesFacet joint painFacet-related painL3/L4 dermatoma decrease Lordosis Lower costal marginLS spine LumbarNo noted deformities Paraspinal muscle Range-of-motion RibsSchober test Spinal tenderness (no)Thoracic spineTrapezius BreastsAxilla Axillae Axillary adenopathy Discrete massFibrocystic change Fibrotic consistency Mammogram Mass (with or without)Nipple discharge Nodularity Palpable massCardiovascular Heart Cor1/6 systolic murmur2/6 systolic ejection murmurAortic insufficiency murmurApical rate Appreciable murmurAtrial contractionsAV blockCarotid bruitsConstant split S1, S2ControlledDiastolic blood pressure Discrete murmurDistant heart soundsEctopic beatFirst degree AV blockGrade 1/6 ejection murmur (at the upper sternal border)Grade 2 systolic ejection murmurHeart tones (normal)Incompetence (no evidence of)Irregular rhythmIrregular tachycardiaJVD (elevated, or no)Mechanical valve sounds (normal)Mitral regurgitationNo gallopsNo murmursNo rub (s)Normal S1 and S2Occasional skipped beats Positive S4Premature atrial contractionsPremature atrial contractionsRegular rate and rhythmRhythmical Sinus rhythm (normal, regular)Sternal borderSternotomy scarT-wave inversionTachycardiaTachycardia with summation gallopTones (normal)Upper sternal borderV5 through V6 unchanged Ventilatory excursions Ventricular enlargement Without S3, S4 ChestSee LungsCorSee Cardiovascular ExtremitiesLimb(s)Musculoskeletal MotorGait10-gram wireAbduction Accessory ossicle Achilles Achilles DTRs Achilles tendon Active extensionAmbulate (d, ing, tion)Ankle jerk (absent, reflex)Ankle joint dorsiflexionAnkle reflexes Ankle-brachial indices were greater than 1 on both right and left Antalgic gaitArthroscopic surgery Avulsion of dorsal ligaments Babinski responsesBallottementBarlow maneuver (infant)BicepsBony prominence BrachioradialisCarotid radial pulseClonus (no)ClubbingCrepitation Crepitus Cross straight leg-raising (positive, negative)Cuboid areaCyanosisDecreased sensationDeep palpation Deep tendon reflexes (1+, 2+, etc)Deformity Discrete pulse Distal edemaDorsalis pedis pulse (palpable)DorsiflexorsDrawer (negative)Dry gangreneDTRs DTRs brisk Dystonic movement Edema (no, 2+, )Effusion (mild)ExostosisExtensionFemoral pulse Finger (PIP joint, MCP joint)FlexionFlexion/extensionFoot evertorsFull range-of-motion FullnessGait (narrow-based, slow, steady)Gait is antalgic to the right with a foot dropGait is steady without swayGangreneGastroc bilaterally Gastroc/soleus muscle complex Gibbous-like deformity Good foot careGood pulses Good strengthGreater trochanters Grip (hand, weak)HalluxHand grip Heel tap (positive)Heel-walkHip click (no)Hips abduct fullyHoffmann testHypoactive bilaterally Impingement syndrome Inferomedial Intention tremorInterphalangeal jointIntertriginous lesionKnee effusionKyphosisLachman’s (negative) Lateral aspect Lateral malleolusLateral subluxation Leg edemaLesser tubercle (upper arm)Light touchLimp Lister tubercle (on the wrist)ManipulationMCL and LCL intactMCP joint (finger)Moccasin-type tinea Monofilament wire sensationMotor tic(s)MTP jointNo clubbing, cyanosis, or edema Normal sensationORIF (open reduction/internal fixation) – hip, Ortolani test (infant)Paronychia Passive extensionPatellaPatellar DTRs Patellar grind Patellofemoral grindPedal edemaPedal pulsesPerfusion Periarticular tendernessPeripheral adenopathy (no)Peripheral edemaPeroneal groovePeroneal tendonsPes planusPinprick PIP joint (finger)Pitting leg edemaPivot (negative)Planar archPlantar fascial originPlantar flexed Plantar flexionPlantar flexorsPopliteal pulses Posterior tibial pulsesPressure ulcer (deep)Pretibial edema PronationRadial pulse Range-of-motion Reflexes Reflexes (2+)Right dorsiflexion is 3+/5Right extensor hallucis longus is 3+/5Rotator cuff Sensation of light touch Sensory (grossly intact, decreased pinprick, etc)Sharp/dull light touch sensationStraight leg-raising (positive, negative)Streaking (no)Strength (5/5, 2/5, etc)Subtalar joint motionSuprapatellar pouchSynovitis (inflammation of the joints)Ten-gram wireTendon jerks Tension signs (negative)Thompson testTibial sag (negative)Tibialis anteriorTic (tics) Tinel’s Toe-walkTone Tophus Trace edema Tremor (mild)TricepsUlcerationsValgus deformitiesVaricosities Varus and valgus stressingVibratory sensation Warm palmsWristPulses (carotid, carotid radial, discrete, dorsalis pedis, femoral, pedal popliteal, posterior tibial, radial)Genitourinary (GU)Anoperineal area ConfirmatoryExternal genitalia (normal)Foley catheter Guaiac negative Normal to inspection and palpation. Pelvic Prepubertal RectoceleUrethra Urethral meatusFAdnexaFAdnexa (palpable, nonpalpable)FAdnexal mass (no)FAtrophic vulvaFCervixFCorpus luteumFCystoceleFCystocele (third degree)FEGBUS (External Genitalia, Bartholin's glands, Urethra & Skene's glands)FEndometriumFEnteroceleFFollicleFFornix (fornices)FFullnessFGravid abdomen FIntroital tissues FIntroitus (normal support)FLabia (swollen) FOvaries normal in size and architecture FPap normalFPap smear FPelvic support of the vaginal walls (excellent)FPer speculumFProlapse FRectovaginalFScanty discharge FSecretory phaseFSpeculumFSubpubic angle (wide)FUterusFUterus (enlarged, asymmetric, nontender, globular)FUterus (retroverted, anteverted, )FVagina (atrophic)FVagina (no masses, no blood)FVaginal apexFVaginal mucosa (moist, healthy to inspection and palpation)FVulvaFVulvar skin healthyMEpididymis MInguinal canalMInguinal herniaMNormal circumcised maleMNormal descended testes MNormal uncircumcised maleMPhallus MScrotumMTesticlesHeartSee Cardiovascular HEENTAcneExudates (no)Facial hirsutismFrontal sinusMaxillary sinusMoist mucous membranesTenderness (positive)Thyroid ophthalmopathy Upper and lower dentures in placeUvula and tongue without fasciculationsWithin normal limits EAuditory canalsEAuricular lymph nodeEBulgingECanalsECerumen ECone of light EEardrums translucentEEardrums well visualizedEEardrums with normal landmarksEExternal canal (no blood)EFluid effusionsEHearing aidEHearing decreasedEInjectedEIntratympanic fluid ELandmarks (good)ELight reflex (good)EMildly retractedENoninjectedEPE tubes patent EPurulent dischargeERednessERetracted (TMs)ERight hypoplastic pinnaESignificant distortionETMETM has blood behind membraneETM with decreased mobilityETM with possible hemotympanumETMs clearETympanic membranesETympanic membranesETympanic membranes mildly retractedETympanic membranes noted to be gray and mobileEWithout visible external auditory canalEyAnisocoria (right pupil 1-2 mm, left 2-3 mm)EyAnterior chambers (normal)EyAnterior segmentEyArcus senilis (bilaterally, positive )EyBoth pupils reactiveEyCataract EyConjunctivae EyCorneaEyCup-to-disc ratioEyDiscs are flat and sharpEyEOMs intact (extraocular muscle)EyEsotropia EyExtraocular movements intactEyExtraocular muscles intact EyFoveal reflexEyFull visual fields bilaterally by confrontationEyFundi with normal discs and vesselsEyFundus, Fundi, funduscopic, EyIcteric EyMyopia, myopic, EyNystagmus EyOptic discsEyPapilledema (no)EyPeripheral hollowsEyPERRULAEyPositive arcus senilisEyProptosis EyPupils equal, round, and reactive to lightEyPupils equally round and reactive to light and accommodationEyRed reflex (positive)EyRoth spots EySclerae clearEySharp discs bilaterally EyTears EyVision 20/20 HAtraumatic HFacial asymmetry HFontanelle (soft, anterior soft)HHair thinningHNC/ATHNormocephalic HNormocephalic , atraumatic HTemporal arteries nonindurated HThinning hairNBlood in nostrilNCarotid (s)NChafing below the naresNClear discharge (positive)NCongestedNCrusty rhinorrheaNDeformity (no)NExcoriated area on septumNFluid leakage (no) NFrontal maxillary sinus cavitiesNHypertrophic inferior turbinatesNIncreased pressure when leans forwardNMaxillary sinus cavity NNaresNNares patent (bilaterally)NNares unobstructed NNasal discharge NNasal membranesNNasal pharynx (nasopharynx) NNostril (left, right)NPurulent discharge NRhinorrheaNRight maxillary sinus cavities NSeptal deviationNSinuses (nontender, )NSinusitis NWithout discharge NYellow-to-green discharge notedTAE fold (aryepiglottic)TAryepiglottic (A-E fold)TCysts TDrainage TErythema, erythematous THyperemicTIndirect mirror lanyngoscopy TIntraorallyTNo exudatesTNodesTOral lesionsTOral mucosaTOropharyngeal lesions (no)TOropharynx clearTPalatal petechiae TPharyngeal rednessTPharyngitisTPharyngitisTPharynxTPost nasopharynx drainageTPosterior oropharynx (dry)TPosterior pharynx TPus pockets TPyriform fossaTRed TRedundant soft palateTSmoker’s pharyngitisTSubmandibular nodesTTender nodesTTonsils (enlarged)TTrachea midlineTUvula TUvula was midlineTWithout erythemaIntegumentSee SkinLungs ChestRespiratory Accessory muscle breathingAeration (good bilaterally)Air entry (good)Airway soundsAnterior chestAnterior/posterior diameter Bibasilar ralesChest wall tenderness (no)ClearClear AP and laterally Clear to A&PClear to auscultation and percussionClear to auscultation bilaterally Coarse rhonchiCoarse, pressed breath soundsContusion (no)CrackleDecreased breath soundsDiffuse wheezesDiminished soundsEgophony (no)Expands adequately Expiratory wheezes Fine basilar ralesGood air entryHyperresonant to percussion Inspiratory crackleLabored breathingLateral aspectLung fields (clear)No rales, wheezes, or rhonchiNo retractionsO2 sat (Oxygen saturation)Occasional rhonchi Peritoneal catheterPressed breath soundsRales (bilateral)Respirations symmetricalRespiratory expansion (good)Symmetric Tachypnea Tactile fremitusThrill (sound)Trauma (no)Upper airway sounds Velcro rales MotorSee Extremities NeckAdenopathy (with or without)Bruit(s)Carotid bruit (no)Carotid pulses Cervical adenopathy Cervical adenopathy in cervical chainCervical chain Cervical lymphadenopathy (no)Cervical spine Decreased range-of-motion globally (mild-to-moderate)Enlarged thyroid Firm thyroidFlat neck veins Generalized tenderness GlandsGoiterHepatojugular refluxJVDLow-lying thyroidLymph 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)SuppleSupraclavicular adenopathy SymmetricThyroid irregularity (no)Thyroid lobe (full)Thyroid nodule Thyromegaly (no)Neurologic (al)Bilateral 6 nerve palsy CNS developmental milestones age appropriate CoordinationCranial nerves II-XII are intact Dystonic movement Finger-to-finger Finger-to-nose Focal deficits (no)NonfocalPhysiologic RectalFleshy polyp on the left posterolateral wall.Good sphincter toneGuaiac negative brown stoolHeme negativeHemoccult negative stool Left inferior lobe apical noduleMasses (no)Nontender prostateNormal sphincter toneNormal tonePolyp Positive nontender external hemorrhoidsProstate (smooth, small, soft)RectoceleSessile polyp Stool heme negativeVault (stool in, rectal)Respiratory See LungsSensory See ExtremitiesSkinIntegumentAcneAcneform lesionsActinic keratosis (keratoses)Asteatotic eczemaBruise, bruises, bruisedDiffuse erythemaEczema Fluctuant Hematomas Hydrated Hyperpigmented rashIntertriginous lesion Keloid formationKeratotic lesionMacular rashMaculopapular lesion Mottled rashPetechiaPigmented lesionPinkPruritic rashPurpuraRaised lesionRash (red, macular)Skin tagsTurgor (good)Vasculitic lesionsVerruca vulgarisViolaceous maculopapular lesionWarm and dryWart Wart-likeWithout lesions TeethDentures (upper, lower)No trauma Vascular examDopplerable left femoral pulse Dorsalis pedis pulseLower extremity pulses all palpable Noted bruitPopliteal pulsePulses in upper extremities equal and symmetrical bilaterallyVital signsAlert and oriented times 3Blood pressureBlood pressure (sitting, standing) Blood pressure with a manual cuff Dizziness Febrile/afebrile Heart rate HeightO2 saturationPulse (regular)Pulse Ox Pulse oximetryPulse rate (##/minute)RespirationsRespiratory rate (regular, irregular, labored, not labored)SaturationStable Temperature (normal)Weight ................
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