Physical Examination Words and Phrases for Medical Transcriptionists
GENERAL / GENERAL APPEARANCE SECTION IN PE:
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
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
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
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
Le Fort I fracture
Le Fort II fracture
Le Fort III 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
NC/AT
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
PERRLA
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 (abbrev)
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 (sounds “shoddy” but its shotty)
trachea central
trachea midline
tender nodes
venous distention at 45 degrees
HEART OR 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
pigeon chest
LUNGS OR PULMONARY EXAM:
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
Infant / Child Physical Exam Samples
EXTREMITIES OR MUSCULOSKELETAL EXAM:
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.
DP and PT pulses.
drop-arm test for rotator cuff tear
DTRs are 2+.
DTRs are brisk.
DTRs are symmetric.
DTRs are trace.
flexion contracture
flexor digitorum
footdrop
functional hallux limitus
genu valgum/genu varum
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
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)
neutral calcaneal stance
no bony or joint abnormalities
No calf tenderness.
No cellulitis.
No cyanosis, clubbing or edema.
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
radial pulse
reflexes are 2+ or absent or trace.
resting calcaneal stance
reverse Lasegue test
single leg stance
snuffbox tenderness
Speed test for biceps
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/GENITALIA:
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
Physical Exam Words and Phrases
PELVIC:
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
BREASTS:
no adenopathy
no dominant masses
no gynecomastia (IN CASE OF MALE PHY EXAM)
no nipple discharges or masses
no skin or nipple retractions
symmetrical
RECTAL:
anal wall
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
BACK/SPINE:
kyphoscoliosis
kyphosis
lordosis
No CVA tenderness.
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
