I have pooled up over the years words that usually are dictated in Physical Examination part, which might be helpful to all in this field. There are many more words other than these...please add them up or forward them to me and I shall add.....
PHYSICAL EXAMINATION
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, eyes, ears, nose and throat: (HEENT)
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
Mouth and throat: (oral examination)
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 examination:
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 Examination:
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)
--------------------------------------------------------------------------------
Abdominal examination:
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
--------------------------------------------------------------------------------
Back:
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
--------------------------------------------------------------------------------
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
--------------------------------------------------------------------------------
Rectal examination:
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
--------------------------------------------------------------------------------
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
--------------------------------------------------------------------------------
Neurological examination:
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
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
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