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: 

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
 

 

EXTREMITIES OR 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.
 
 
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.


More Physical Exam Samples      

 

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
 
 
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

 

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

 






Comments