General Multi-System Exam
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
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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
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
General Multi-System Exam
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 wellvisualized/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
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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
Throat/mouth
aphthae
aphthous ulcers
bifid
bifid uvula
buccal mucosa
cleft palate
dentition
edentulous
erythema
exudate
General Multi-System Exam
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
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
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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
General Multi-System Exam
Cardiac
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
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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)
Back/Spine
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
General Multi-System Exam
scoliosis
Abdominal
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
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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
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
General Multi-System Exam
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
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
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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
General Multi-System Exam
aphagia
aphasia
asymmetry
ataxia
ataxic gait
Babinski sign
(negative/positive/withdrawal/equivoc
al)
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
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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/withdr
awal)
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
General Multi-System Exam
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
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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