General Multi-System Exam Vocabulary List
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psoriasis/psoriatic
isocoria/isocoric (meaning the goiter
purpura
pupils are equal bilaterally)
hepatojugular reflux (HJR)
rash, petechiae, or purpura
lenticular opacification
jugular venous distention
scleredema
macular degeneration
(JVD)
spider angiomata
nystagmus
lymph nodes not
stigmata of liver disease
opacification
palpable/palpable, hard,
tenting (skin/tissue)
opacified
immobile, fixed, freely mobile
turgor
papilledema
lymphadenopathy
ptosis (pronounced TOH-SIS) multinodular goiter
Head
raccoon
pharynx
atraumatic
rapid eye movements (REM)
shotty lymph nodes [NOT
atraumatic, normocephalic
red reflex
shoddy]
(AT/NC)
retinopathy
stridor
Battle's sign (cap the "B" sclerae anicteric/icteric
supple
named for Dr. William H.
slit-lamp examination
thyroid not palpable
Battle)
strabismus
thyromegaly
flattening of the (left/right)
visual acuity
venous distention at 45
nasolabial fold
degrees
Ears
fontanel (infant exam)
Chest/Breast
macrocephaly/macrocephalic auditory canal
megacephaly/megacephalic
cerumen
AP diameter (anteriormicrocephaly/microcephalic
injected
posterior diameter)
nasolabial fold
myringotomy tubes
areola
normocephalic
poor light reflex
atrophic
normocephalic, atraumatic
TMs (tympanic membranes)
axilla ( No adenopathy or
(NC/AT)
tympanic membranes intact lymphadenopathy, no nodes
raccoon eyes
red/bulging/dull
felt.)
breasts atrophic (older
Eyes
Nose
women)
Pupils equal, round, and
boggy turbinates
gynecomastia (men)
Vital signs
reactive to light and
congested
mastectomy
Blood pressure: 120/80 mm
accommodation. (PERRLA)
flattening of the nasolabial fold no nipple discharge
Hg (millimeters of mercury)
Pupils equal, round, and
nasolabial fold
no lumps or masses
Pulse rate: 80 (per minute)
reactive to light. (PERRL)
inferior turbinate
permanent pacemaker
(see "Cardiac Exam" below)
Pupils equal and reactive to
polyps
status post mastectomy
Respiratory rate: 18 (per
light. (PERL)
septal deviation
sternum
minute), labored/unlabored
(above may be dictated as
sinus
sternotomy scar
Temperature: 98.6 degrees F. PURL or PURL-LAH)
turbinate/turbinate
Tanner
(sometimes TPupils (fixed/dilated/pinpoint)
hypertrophy
thoracic
max=temperature maximum)
anicteric
thorax
Throat/mouth
afebrile/febrile
arcus senilis
Lungs
arterial pulsation
aphthae
Skin
Battle's sign
aphthous ulcers
accessory muscles of
abrasions
best-corrected visual acuity
bifid
respiration
complexion cataract
bifid uvula
adventitious sounds
flushed/pale/pallor/ruddy
conjunctivae pink, not
buccal mucosa
AP diameter normal/increased
decubital
injected, clear, normal,
cleft palate
atelectasis
decubitus ulcers (NOT
muddy, no pallor
dentition
clear to auscultation and
decubiti)
cornea clear/cloudy
edentulous
percussion (A and P/P and A)
ecchymosis, pl. ecchymoses
corneal reflex intact
erythema
coarse rales
eczema
disk/disc margins wellexudate
costophrenic angles
eczematoid
delineated
hard palate
crackles/crackling
eczematous
disks/discs sharp
mucous membranes moist/dry crepitant rales
edema
enucleated
palate
crepitation
edematous
extraocular movements
pharynx
crepitus
erythema
(EOM) (may be dictated EEprotruded tongue midline
Cheyne-Stokes breathing
erythematous
OHM)
soft palate
dullness to percussion
eschar
extraocular movements intact temporomandibular joint
dyspnea
herpes simplex
(EOMI) (may be dictated EEthrush
dyspnea on exertion
herpes zoster
OH-MEE)
tongue well-papillated
E to A changes (egophony)
herpetic lesion
fundi well-visualized/not well- uvula moves on phonation
[patient says "EEEE" MD
lichenoid edema
visualized/not examined
uvula and tongue midline
hears "AAAAA"]
maculopapules
funduscopic examination,
egophony
Neck
maculopapular rash
funduscopy
end-expiratory wheeze
pale
homonymous hemianopsia
carotids 2+ and equal
expiratory time
pallor
H or E (hemorrhage or
bilaterally
normal/prolonged
petechiae
exudate)
carotid bruit
expiratory wheeze
plethoric
iridectomy
cervical adenopathy
expiratory wheeze 1+, 2+, etc.
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, wellnourished
General Multi-System Exam Vocabulary List
rub
McBurney's point (location to
S1, S2, S3, S4
test for appendix)
S1 equals S2
morbid obesity
S1 and S2 normal, no S3 or
Murphy's sign
S4
obese
S3 gallop
organomegaly
second heart sound (S2)
palpable, nonpalpable
supraventricular tachycardia
protuberant
(SVT)
rebound
systolic ejection murmur
rebound tenderness
tachycardia
scaphoid
Cardiac
third heart sound (S3)
scars of previous surgery
A2 louder than P2
thrill
tender, nontender
aortic click
tricuspid regurgitation
visceromegaly
aortic regurgitation
ventricular fibrillation (often
Landmarks:
apical systolic murmur
dictated Vee-Fib)
axillary line
arrhythmias
ventricular tachycardia (often
costophrenic angle
asystole
dictated Vee-Tak)
costovertebral angle
atrial fibrillation (often dictated
epigastric
Back/Spine
Ay-Fib or AF)
inguinal
atrial flutter
C-spine
left costal margin
bradycardia
cervical spine
left lower quadrant
cardiomegaly
costovertebral angle
left upper quadrant
click
tenderness (CVA
ligament of Treitz
diastolic murmur
tenderness/CVAT)
McBurney's point
first heart sound (S1)
dorsal spine
midclavicular line
first and second heart sounds kyphosis
Murphy's point
normal; no third or fourth heart kyphoscoliosis
paramedian
sound
lumbar
parasternal border
fourth heart sound
lumbosacral
right lower quadrant
ejection murmur
palpation and percussion
right upper quadrant
ejection systolic murmur
paravertebral
right costal margin
gallop
point tenderness
subclavicular
grade 1/6, 2/6, 3/6, 4/6, 5/6*
radiation
suprapubic area
grade I, grade II, grade III,
referred pain
symphysis pubis
grade IV, grade V, grade VI*
sacrum
xiphoid to pubis
heart sound
sciatica
xiphoid process
heave
scoliosis
Extremities
holosystolic murmur
Abdominal
intercostal space
above-knee amputation (AKA)
irregularly irregular
ascites
arc of motion
knock
ballottable
below-knee amputation (BKA)
MAT (multifocal atrial
bowel sounds normal
CCE (cyanosis, clubbing or
tachycardia)
(normoactive, hyperactive,
edema)
midclavicular line
hypoactive,
calf tenderness
mitral valve prolapse
high-pitched, inaudible,
capillary refill
mitral regurgitation
tympanitic, decreased,
claudication
multifocal atrial tachycardia
diminished)
clubbing
(MAT)
costovertebral angle
cords
murmur
tenderness (CVA
cyanosis
murmur radiating to the axilla
tenderness/CVAT)[back
decubitus ulcer
or neck
exam]
Doppler
normal sinus rhythm (NSR)
distended, nondistended
dorsalis pedis pulses
P2 louder than A2
exogenous obesity
DP/PT - dorsalis pedis,
parasternal border
fluid wave
posterior tibial (pulses)
pericardial knock
guarding
edema
physiologically split
liver and spleen
edema 1+ (2+, 3+)
PMI - point of maximum
not palpable
edematous
impulse
1-2 fingerbreadths below right femoral pulse
point of maximum impulse
costal margin
full range of motion
(PMI) in fifth intercostal space hepatomegaly
hip click (baby examination)
premature ventricular
hepatosplenomegaly
Heberden's nodes of
contractions (PVC)
liver, spleen and kidneys not
osteoarthritis
prosthetic click/sound
palpable/not felt
Homans' sign
PVC - premature ventricular
spleen enlarged/not
Lachman's sign (often
contractions
enlarged/not felt
pronounced "lock-man's")
regular sinus rhythm (RSR)
tender, nontender
mottling
rapid ventricular response
pedal edema
forced expiratory time
hyperresonant
hyperventilation
hypoventilation
moist rales
pleural rub
rales
rhonchi
rub
wheeze
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peripheral pulses
pitting edema
popliteal pulse
posterior tibial pulse (PT)
pulses 2+ and equal bilaterally
range of motion
varicose veins
varicosities
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
Rectal
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
Neurologic
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, broadbased, 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
General Multi-System Exam Vocabulary List
pinprick
suicidal ideation/suicidality
plantar flexion
(SI)
plantar reflexes
tangential/tangentiality
(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
Axis I: Clinical disorders,
syndromes and/or other areas
of concern
Axis II: Personality disorders
and mental retardation
Axis III: Medical conditions
(which may impact emotions)
Axis IV: Psychosocial
stressors (death, divorce, loss
of job, etc.)
Axis V: Global assessment of
functioning.
dangerous ideation
delusions
depression
flat affect
flight of ideas
grandiose/grandiosity
hallucinations
homicidal ideation (HI)
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
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