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 Page 1 of 8 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 Page 2 of 8 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 Page 3 of 8 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 Page 4 of 8 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 Page 5 of 8 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 Page 6 of 8 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 Page 7 of 8 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 Page 8 of 8