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WORDS & PHRASES COMMONLY DICTATED UNDER THE FOLLOWING SECTIONS IN ROS:

CONSTITUTIONAL:

had some shaking

negative fever or chills

no fever, generalized weakness or malaise

no pyrexia or chills. No weakness or fatigue.

no significant weight changes

no unexplained weight loss

no weight loss, fever, chills, weakness or fatigue

the patient denies fever, weight loss, night sweats, fatigue or bleeding

the patient is rather clammy, pale-looking

arcus senilis

aural fullness

conjunctivae pink, no scleral icterus

contact lens worn

double vision

ears and nose externally normal

goiter

hard of hearing

Head is normocephalic and atraumatic. Eyes, ears, nose and throat are unremarkable

moist buccal mucosa

mouth has no sores

nasal discharge

negative for false teeth

negative for glaucoma or cataracts

negative for masses, hoarseness or snoring

no bleeding gingivae

no change in hearing

no diplopia or blurred vision

no dysgeusia

no dysphagia, dysphonia.

no earache, sore throat or runny nose

no epistaxis or rhinorrhea.

no eye pain

no glossodynia

no hearing loss

no lid lag, no exophthalmos, no xanthelasma

no mucosal lesions

no mucosal pallor

no otalgia, otorrhea

no photophobia

no postnasal drip

no scleral icterus

no scotomata

no sneezing or congestion

No tenderness or difficulty in swallowing

no thrush

no tinnitus or vertigo

no vision disturbances

no visual loss

no xerostomia

patient has full denture plates

PERRL, EOMI

pharynx normal

sinus congestion

The patient wears corrective glasses for reading

ulcerations in mouth secondary to chemotherapy

visual field deficit

wears dentures

clear to auscultation bilaterally

denies any tuberculosis, pneumonia, asthma, pleurisy, bronchitis or sinusitis

dyspnea on exertion

negative shortness of breath, cough, sputum production

no cough or difficulty breathing

no hemoptysis

no hiccups

no history of pulmonary TB

no pleurisy

no PND or orthopnea

there was good respiratory effort

chest pressure

denies history of heart attack

denies night cramps

denies orthostasis

denies substernal or radiating chest pain

negative chest pain on exertion or palpation

no angina

No chest pain, chest pressure, chest discomfort

no history of valve disease

no palpitations or syncope

no precordial pain

No squeezing, strangling, tightness, heaviness or aching about the chest, neck or axilla

positive/negative for hypertension

bright red blood per rectum

denies abdominal fullness

denies black tarry stools

has GERD

melena

no abdominal pain or blood

no acid reflux, heartburn

no anorexia

no constipation

No constipation, diarrhea, black stools, bright red blood per rectum

no epigastric pain

no GI bleed

no hematemesis

no hematochezia

no hemorrhoids

no melanotic stools

no melenemesis

no nausea, vomiting or diarrhea

no odynophagia

no rectal bleeding

GENITOURINARY SYSTEM:

anuric

burning on urination

denies any CVA or suprapubic tenderness

denies pregnancy

diminished urine output

flank pain

has vaginal bleeding

history of carcinoma of the prostate

LMP is current

microscopic hematuria

no difficulty urinating

no dysuria, polyuria, frequency, urgency, hesitancy

no female discharge

no gross blood in the urine

no hematuria or dysuria

no incontinence of bowel or bladder

no kidney stones in the past

no nocturia

no pyuria

no urinary retention

no urinary tract infections

on hemodialysis

pregnancy, last menstrual period

urinary incontinence

varicocele

Review of Systems Transcribed Examples

MUSCULOSKELETAL SYSTEM:

no focal joint pain or stiffness

no joint swelling

no muscle pains

no muscle, back pain, joint pain or stiffness

no myalgias or arthralgias

no neck pain or back pain

no trauma

change in level of consciousness

denies any seizures, convulsions, unconsciousness, speech difficulty or ataxia.

difficult to perform because of poor patient cooperation

negative/positive for migraines

no change in bowel or bladder control

no confusion

no focal weakness

no headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities

no history of TIA, CVA

no lightheadedness or slurred speech

no motor or sensory loss

no paresthesias, fasciculations, seizures or weakness

no strokes or seizures

numbness and tingling, stocking/glove distribution

no delusions

no depression, no loss of interest in normal activity or change in sleep pattern

no disorder of thought or mood

no hallucinations or suicidal ideations

no history of depression or anxiety

no mania

no change in skin, hair, nails

no dermatitis

no evidence of squamous or basal cell CA

no rash or itching

no skin rash or skin lesions

no unusual skin spots

positive for hives

vesicular lesions

negative for thyroid abnormalities

negative/positive for diabetes

no fibroid abnormalities

no heat or cold intolerance, polyuria or polydipsia

no sweating

denies abnormal bleeding

denies bleeding disorder

negative for anemia or blood dyscrasias

no abnormal hemorrhaging

no anemia

no easy bruisability

no easy bruising or bleeding

no history of blood clots

no unusual infections or bleeding

no enlarged nodes

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acute respiratory distress syndrome (ARDS)

aerosol therapy

air trapping

airflow

airflow obstruction

alveolar volume

anosmia

aphonia

arterial blood gas (ABG)

asbestosis

aspiration pneumonia

assist-controlled mechanical ventilation (ACMV)

AutoPap

BiPAP

bronchial washings

bronchiogenic

bronchodilator therapy

bronchoscopy

bronchospasm

chronic obstructive pulmonary disease (COPD)

CO2

CPAP (continuous positive airway pressure)

CPAP titration level was _____ cm of water

daytime somnolence

diffusing capacity

DLCO (diffusing capacity of lung for carbon monoxide)

dyspnea on exertion

emphysema

empyema

endotracheal intubation

Epworth sleepiness scale

ethmoid sinuses

exercise-induced asthma

FEF (forced expiratory flow)

FEF25-75%

FEV1

FEV1/FVC

fiberoptic bronchoscopy

FiO2

flow volume loop

FRC (functional residual capacity)

frontal sinuses

FVC

ground-glass appearance

ground-glass opacification

hand-held nebulizer

hemoptysis

hypercapnia

hyperinflation

hyperpnea

hypoxemia

hypoxia

ILD (interstitial lung disease)

incentive spirometry

inhaled corticosteroid

IPF (interstitial pulmonary fibrosis)

IPPV (intermittent positive pressure ventilation)

lingula

maxillary sinuses

maximum voluntary ventilation

MDI (metered-dose inhaler)

MVV (maximum voluntary ventilation)

nocturnal polysomnography

nonrebreathing mask

O2

obstructive defect

obstructive impairment

obstructive lung disease

orthopnea

OSA (obstructive sleep apnea)

overnight oximetry

parenchyma

parenchymal

PCO2

PEEP (positive end-expiratory pressure)

PFTs (pulmonary function tests)

PND (paroxysmal nocturnal dyspnea)

Pneumocystis carinii

Pneumovax

PO2

polysomnography

PPD (tuberculosis test)

PSG (polysomnography)

pulmonary artery wedge pressure

pulmonary capillary wedge pressure

pulmonary hypertension

rebreathing mask

restrictive impairment

saturations on room air

sawtooth pattern

Shiley tracheostomy tube

silicosis

sleep disordered breathing

somnolence

spirometry

steroids with taper

three-pillow orthopnea

tidal volume

TLC (total lung capacity)

TLV (total lung volume)

tracheostomy cuff

tracheostomy stoma

two-pillow orthopnea

updraft treatment

Venti mask

ventilation/perfusion (V/Q) scan

Wegener granulomatosis

witnessed apneas

work of breathing (e.g., increased work of breathing)

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abduction brace

abduction hip splint

abduction pillow

active-assisted range-of-motion exercise

activities of daily living

adaptive devices

American Spinal Injury Association (ASIA) scale

ankle-foot orthosis or AFO

ankle-pump exercise

antidecubitus mattress

aquatic therapy

arm trough

aspiration precautions

assistive devices

balance board

bathroom equipment

bed mobility

bed rails

bedside commode

bed-to-wheelchair transfers

broad-based cane

broad-based gait

buddy strap/splint

Bunny boot

calcaneal stance

chin tuck technique (dysphagia patients)

compensatory techniques

contact guard assistance

CPM (continuous passive motion) device

dependent for all self-care activities

dressing stick

eggcrate mattress

electrical stimulation

elevating leg rest

energy conservation techniques and pacing

footdrop gait

front-wheel walker

functional transfers

gentle passive range of motion

give-way weakness

Glasgow coma scale score

grip strength

halo vest

hand grasp strength

handicap parking placard

HBO therapy

heel lift

hospital bed

Hoyer lift

hygiene, feeding, grooming, upper and lower body dressing,

and transfer skills

joint laxity

Kydex jacket

lightweight wheelchair

LiteGait device

long handle shoe horn

long handle sponge

lumbosacral corset

maximal assistance, moderate assistance, minimal assistance

maximal assistance for grooming

Minerva vest

minimal/maximal assistance

modified independence level

moist heat therapy

Moon boot

motorized scooter

motorized wheelchair

one-person assistance, two-person assistance

oral motor control

parallel bars

passive resistive exercise

physical therapy, occupational therapy, rehab nursing, therapeutic

recreation

pregait and gait training

pressure relief ankle foot orthosis or PRAFO

psychomotor performance

quad cane

quad knobs and brake extenders

raised toilet seat

Rancho ankle foot control device

range of motion

recreational therapy

requires setup for

rickshaw rehabilitation exerciser

ROHO bed

rolling walker

safety awareness

self-care independence

self-care skills

self-propel wheelchairs

shoe lift

shower chair

single-point cane

sit to stand

sitting/standing balance

sliding board transfers

sock aid and reacher

spinal cord injury orientation session

spinal precautions

standard leg rest

standby to contact guard assistance

supervised level with

swing-through gait

swing-through phase of ambulation

team conference

TED hose

Thera-Band

therapeutic recreation

toe-touch weightbearing status

toilet-to-tub/shower transfers

total dependence

trapeze

Trendelenburg gait

Vail bed

Venodyne boot

vibratory stimulation

weightbearing as tolerated

whirlpool therapy

PODIATRY TERMS:

ankle dorsiflexion

balls of feet

Birkenstock orthotic/shoe

bunion

calcaneal cuboid joint

collapse of the arch

cryptotic nails

curve-lasted shoe

debride nails

dystrophic nails

exostosis

first MJP

functional hallux limitus

gel heel lifts

Haglund deformity

hallux

HAV deformity

heel pads

heel protectors

hyperostosis

ingrown nails

IPJ ossicle

longitudinal arch

metatarsus adductus deformity

midtarsal joint sag

navicula

neutral calcaneal stance

onychauxis

onychocryptosis

onychomycosis

orthotics

plantar fasciitis

plantarflexed

poststatic dyskinesia

proprioceptive exercises

raise and invert heels

sinus tarsi area

Spenco inserts

Superfeet orthotic insole

too-many-toe sign

tyloma

underlapping toe

varus rearfoot wedge

visual gait analysis

walking cast boot

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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

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

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