(General)
Physical Examination Word List
Above-stated age
Ambulate (d, tion, ing)
Anxious
Appropriate for age
Appropriate for age
Benign
Combative
Conscious
Cooperative
Cordial
Cushingoid facies
CVA tenderness
Deferred
Developmental milestones age appropriate
Diaphoretic
Disheveled
Dizziness
Dysphoric
Emotional
Fatigued
Fingerstick
Frail
Grossly intact
Healthy-appearing
Hearty
Hygiene (poor, good)
Icterus
Ill-appearing
Immunizations up-to-date
Infection (without evidence of, )
Jaundice
Lethargic
Mask-face-appearing
Mild distress
Mood changes
No acute discomfort
No acute distress
No apparent distress
Normal
Not in any distress
Older than stated age
Oral hygiene good
Oriented times 3 with proper affect
Overweight
Pale
Pallor

Abdomen
Periorbital puffiness
Pleasant
Polypoid lesion
Proper affect
Psychological disturbances
Psychosocially stable
Pulse oximetry (Pulse Ox)
Responsive
Sad
Thin
Uncooperative
Unhappy
Unremarkable
Up-to-date immunizations
Upset
Vertiginous dizziness
Vertigo
Vigorous
Well-developed
Well-healed
Well-nourished
Within normal limits
Young appearing
Younger than stated age
Active bowel sounds
Bladder
Bowel sounds present
Diffuse tenderness
Enlarged liver
Epigastric tenderness to palpation
Flat
Gravid (pregnant)
Guarding (no)
Hepatosplenomegaly (no)
High pitched bowel sounds
Infraumbilical scar
Liver edge (no)
Liver palpable
Liver without enlargement
Location (right lower quadrant tenderness, etc)
Masses (no)
Multiple striae
Murphy sign (positive)
Nondistended
Nontender
Normoactive bowel sounds
Obese
Obturator sign (positive)
Organomegaly

Back
Breasts
Palpable masses
Positive bowel sounds
Protuberant
Psoas sign (positive)
Pulsatile masses (no)
Rebound (no)
Rebound guarding (positive)
Rotund
Rushes (a bowel sound)
Scaphoid
Scar (midline, well-healed)
Silver striae
Spleen tip (no)
Splenomegaly
Supraumbilical region
Without distention
Costovertebral angle tenderness (no, negative)
CVA tenderness (no)
Degenerative disc disease
Discogenic pain
Dorsal kyphosis
End plate convexities
Facet joint pain
Facet-related pain
L3/L4 dermatoma decrease
Lordosis
Lower costal margin
LS spine
Lumbar
No noted deformities
Paraspinal muscle
Range-of-motion
Ribs
Schober test
Spinal tenderness (no)
Thoracic spine
Trapezius
Axilla
Axillae
Axillary adenopathy
Discrete mass
Fibrocystic change
Fibrotic consistency
Mammogram
Mass (with or without)
Nipple discharge
Nodularity
Palpable mass

Cardiovascular
Heart
Cor
Chest
1/6 systolic murmur
2/6 systolic ejection murmur
Aortic insufficiency murmur
Apical rate
Appreciable murmur
Atrial contractions
AV block
Carotid bruits
Constant split S1, S2
Controlled
Diastolic blood pressure
Discrete murmur
Distant heart sounds
Ectopic beat
First degree AV block
Grade 1/6 ejection murmur (at the upper sternal border)
Grade 2 systolic ejection murmur
Heart tones (normal)
Incompetence (no evidence of)
Irregular rhythm
Irregular tachycardia
JVD (elevated, or no)
Mechanical valve sounds (normal)
Mitral regurgitation
No gallops
No murmurs
No rub (s)
Normal S1 and S2
Occasional skipped beats
Positive S4
Premature atrial contractions
Premature atrial contractions
Regular rate and rhythm
Rhythmical
Sinus rhythm (normal, regular)
Sternal border
Sternotomy scar
T-wave inversion
Tachycardia
Tachycardia with summation gallop
Tones (normal)
Upper sternal border
V5 through V6 unchanged
Ventilatory excursions
Ventricular enlargement
Without S3, S4
See Lungs

Cor
Extremities
Limb(s)
Musculoskeletal
Motor
Gait
See Cardiovascular
10-gram wire
Abduction
Accessory ossicle
Achilles
Achilles DTRs
Achilles tendon
Active extension
Ambulate (d, ing, tion)
Ankle jerk (absent, reflex)
Ankle joint dorsiflexion
Ankle reflexes
Ankle-brachial indices were greater than 1 on both right and left
Antalgic gait
Arthroscopic surgery
Avulsion of dorsal ligaments
Babinski responses
Ballottement
Barlow maneuver (infant)
Biceps
Bony prominence
Brachioradialis
Carotid radial pulse
Clonus (no)
Clubbing
Crepitation
Crepitus
Cross straight leg-raising (positive, negative)
Cuboid area
Cyanosis
Decreased sensation
Deep palpation
Deep tendon reflexes (1+, 2+, etc)
Deformity
Discrete pulse
Distal edema
Dorsalis pedis pulse (palpable)
Dorsiflexors
Drawer (negative)
Dry gangrene
DTRs
DTRs brisk
Dystonic movement
Edema (no, 2+, )
Effusion (mild)
Exostosis
Extension
Femoral pulse
Finger (PIP joint, MCP joint)

Flexion
Flexion/extension
Foot evertors
Full range-of-motion
Fullness
Gait (narrow-based, slow, steady)
Gait is antalgic to the right with a foot drop
Gait is steady without sway
Gangrene
Gastroc bilaterally
Gastroc/soleus muscle complex
Gibbous-like deformity
Good foot care
Good pulses
Good strength
Greater trochanters
Grip (hand, weak)
Hallux
Hand grip
Heel tap (positive)
Heel-walk
Hip click (no)
Hips abduct fully
Hoffmann test
Hypoactive bilaterally
Impingement syndrome
Inferomedial
Intention tremor
Interphalangeal joint
Intertriginous lesion
Knee effusion
Kyphosis
Lachman’s (negative)
Lateral aspect
Lateral malleolus
Lateral subluxation
Leg edema
Lesser tubercle (upper arm)
Light touch
Limp
Lister tubercle (on the wrist)
Manipulation
MCL and LCL intact
MCP joint (finger)
Moccasin-type tinea
Monofilament wire sensation
Motor tic(s)
MTP joint
No clubbing, cyanosis, or edema

Normal sensation
ORIF (open reduction/internal fixation) – hip,
Ortolani test (infant)
Paronychia
Passive extension
Patella
Patellar DTRs
Patellar grind
Patellofemoral grind
Pedal edema
Pedal pulses
Perfusion
Periarticular tenderness
Peripheral adenopathy (no)
Peripheral edema
Peroneal groove
Peroneal tendons
Pes planus
Pinprick
PIP joint (finger)
Pitting leg edema
Pivot (negative)
Planar arch
Plantar fascial origin
Plantar flexed
Plantar flexion
Plantar flexors
Popliteal pulses
Posterior tibial pulses
Pressure ulcer (deep)
Pretibial edema
Pronation
Radial pulse
Range-of-motion
Reflexes
Reflexes (2+)
Right dorsiflexion is 3+/5
Right extensor hallucis longus is 3+/5
Rotator cuff
Sensation of light touch
Sensory (grossly intact, decreased pinprick, etc)
Sharp/dull light touch sensation
Straight leg-raising (positive, negative)
Streaking (no)
Strength (5/5, 2/5, etc)
Subtalar joint motion
Suprapatellar pouch
Synovitis (inflammation of the joints)
Ten-gram wire

Tendon jerks
Tension signs (negative)
Thompson test
Tibial sag (negative)
Tibialis anterior
Tic (tics)
Tinel’s
Toe-walk
Tone
Tophus
Trace edema
Tremor (mild)
Triceps
Ulcerations
Valgus deformities
Varicosities
Varus and valgus stressing
Vibratory sensation
Warm palms
Wrist
Pulses (carotid, carotid radial, discrete, dorsalis pedis, femoral, pedal popliteal, posterior tibial, radial)
Genitourinary (GU) Anoperineal area
Confirmatory
External genitalia (normal)
Foley catheter
Guaiac negative
Normal to inspection and palpation.
Pelvic
Prepubertal
Rectocele
Urethra
Urethral meatus
F Adnexa
F Adnexa (palpable, nonpalpable)
F Adnexal mass (no)
F Atrophic vulva
F Cervix
F Corpus luteum
F Cystocele
F Cystocele (third degree)
F EGBUS (External Genitalia, Bartholin's glands, Urethra & Skene's glands)
F Endometrium
F Enterocele
F Follicle
F Fornix (fornices)
F Fullness
F Gravid abdomen
F Introital tissues

Heart
HEENT
F Introitus (normal support)
F Labia (swollen)
F Ovaries normal in size and architecture
F Pap normal
F Pap smear
F Pelvic support of the vaginal walls (excellent)
F Per speculum
F Prolapse
F Rectovaginal
F Scanty discharge
F Secretory phase
F Speculum
F Subpubic angle (wide)
F Uterus
F Uterus (enlarged, asymmetric, nontender, globular)
F Uterus (retroverted, anteverted, )
F Vagina (atrophic)
F Vagina (no masses, no blood)
F Vaginal apex
F Vaginal mucosa (moist, healthy to inspection and palpation)
F Vulva
F Vulvar skin healthy
M Epididymis
M Inguinal canal
M Inguinal hernia
M Normal circumcised male
M Normal descended testes
M Normal uncircumcised male
M Phallus
M Scrotum
M Testicles
E
E
E
E
E
E
See Cardiovascular
Acne
Exudates (no)
Facial hirsutism
Frontal sinus
Maxillary sinus
Moist mucous membranes
Tenderness (positive)
Thyroid ophthalmopathy
Upper and lower dentures in place
Uvula and tongue without fasciculations
Within normal limits
Auditory canals
Auricular lymph node
Bulging
Canals
Cerumen
Cone of light

E
E
E
E
E
E
Ey
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Eardrums translucent
Eardrums well visualized
Eardrums with normal landmarks
External canal (no blood)
Fluid effusions
Hearing aid
Hearing decreased
Injected
Intratympanic fluid
Landmarks (good)
Light reflex (good)
Mildly retracted
Noninjected
PE tubes patent
Purulent discharge
Redness
Retracted (TMs)
Right hypoplastic pinna
Significant distortion
TM
TM has blood behind membrane
TM with decreased mobility
TM with possible hemotympanum
TMs clear
Tympanic membranes
Tympanic membranes
Tympanic membranes mildly retracted
Tympanic membranes noted to be gray and mobile
Without visible external auditory canal
Anisocoria (right pupil 1-2 mm, left 2-3 mm)
Anterior chambers (normal)
Anterior segment
Arcus senilis (bilaterally, positive )
Both pupils reactive
Cataract
Conjunctivae
Cornea
Cup-to-disc ratio
Discs are flat and sharp
EOMs intact (extraocular muscle)
Esotropia
Extraocular movements intact
Extraocular muscles intact
Foveal reflex
Full visual fields bilaterally by confrontation
Fundi with normal discs and vessels
Fundus, Fundi, funduscopic,
Icteric
Myopia, myopic,

H
N
N
N
N
N
N
H
H
H
H
H
H
H
Ey
Ey
Ey
H
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
Ey
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Nystagmus
Optic discs
Papilledema (no)
Peripheral hollows
PERRULA
Positive arcus senilis
Proptosis
Pupils equal, round, and reactive to light
Pupils equally round and reactive to light and accommodation
Red reflex (positive)
Roth spots
Sclerae clear
Sharp discs bilaterally
Tears
Vision 20/20
Atraumatic
Facial asymmetry
Fontanelle (soft, anterior soft)
Hair thinning
NC/AT
Normocephalic
Normocephalic , atraumatic
Temporal arteries nonindurated
Thinning hair
Blood in nostril
Carotid (s)
Chafing below the nares
Clear discharge (positive)
Congested
Crusty rhinorrhea
Deformity (no)
Excoriated area on septum
Fluid leakage (no)
Frontal maxillary sinus cavities
Hypertrophic inferior turbinates
Increased pressure when leans forward
Maxillary sinus cavity
Nares
Nares patent (bilaterally)
Nares unobstructed
Nasal discharge
Nasal membranes
Nasal pharynx (nasopharynx)
Nostril (left, right)
Purulent discharge
Rhinorrhea
Right maxillary sinus cavities
Septal deviation
Sinuses (nontender, )

Integument
Lungs
Chest
Respiratory
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
N
N
N
T
Sinusitis
Without discharge
Yellow-to-green discharge noted
AE fold (aryepiglottic)
Aryepiglottic (A-E fold)
Cysts
Drainage
Erythema, erythematous
Hyperemic
Indirect mirror lanyngoscopy
Intraorally
No exudates
Nodes
Oral lesions
Oral mucosa
Oropharyngeal lesions (no)
Oropharynx clear
Palatal petechiae
Pharyngeal redness
Pharyngitis
Pharyngitis
Pharynx
Post nasopharynx drainage
Posterior oropharynx (dry)
Posterior pharynx
Pus pockets
Pyriform fossa
Red
Redundant soft palate
Smoker’s pharyngitis
Submandibular nodes
Tender nodes
Tonsils (enlarged)
Trachea midline
Uvula
Uvula was midline
Without erythema
See Skin
Accessory muscle breathing
Aeration (good bilaterally)
Air entry (good)
Airway sounds
Anterior chest
Anterior/posterior diameter
Bibasilar rales
Chest wall tenderness (no)
Clear
Clear AP and laterally
Clear to A&P

Motor
Neck
Clear to auscultation and percussion
Clear to auscultation bilaterally
Coarse rhonchi
Coarse, pressed breath sounds
Contusion (no)
Crackle
Decreased breath sounds
Diffuse wheezes
Diminished sounds
Egophony (no)
Expands adequately
Expiratory wheezes
Fine basilar rales
Good air entry
Hyperresonant to percussion
Inspiratory crackle
Labored breathing
Lateral aspect
Lung fields (clear)
No rales, wheezes, or rhonchi
No retractions
O2 sat (Oxygen saturation)
Occasional rhonchi
Peritoneal catheter
Pressed breath sounds
Rales (bilateral)
Respirations symmetrical
Respiratory expansion (good)
Symmetric
Tachypnea
Tactile fremitus
Thrill (sound)
Trauma (no)
Upper airway sounds
Velcro rales
See Extremities
Adenopathy (with or without)
Bruit(s)
Carotid bruit (no)
Carotid pulses
Cervical adenopathy
Cervical adenopathy in cervical chain
Cervical chain
Cervical lymphadenopathy (no)
Cervical spine
Decreased range-of-motion globally (mild-to-moderate)
Enlarged thyroid
Firm thyroid
Flat neck veins

Neurologic (al)
Rectal
Respiratory
Generalized tenderness
Glands
Goiter
Hepatojugular reflux
JVD
Low-lying thyroid
Lymph nodes (no enlargement)
Lymphadenopathy (with or without)
No point tenderness
Nodularity (no, without)
Nontender
Occipital movement (good, anterior)
Range-of-motion (full, limited, good)
Submandibular nodes (large)
Supple
Supraclavicular adenopathy
Symmetric
Thyroid irregularity (no)
Thyroid lobe (full)
Thyroid nodule
Thyromegaly (no)
Bilateral 6 nerve palsy
CNS developmental milestones age appropriate
Coordination
Cranial nerves II-XII are intact
Dystonic movement
Finger-to-finger
Finger-to-nose
Focal deficits (no)
Nonfocal
Physiologic
Fleshy polyp on the left posterolateral wall.
Good sphincter tone
Guaiac negative brown stool
Heme negative
Hemoccult negative stool
Left inferior lobe apical nodule
Masses (no)
Nontender prostate
Normal sphincter tone
Normal tone
Polyp
Positive nontender external hemorrhoids
Prostate (smooth, small, soft)
Rectocele
Sessile polyp
Stool heme negative
Vault (stool in, rectal)
See Lungs

Sensory
Skin
Integument
Teeth
Vascular exam
Vital signs
See Extremities
Acne
Acneform lesions
Actinic keratosis (keratoses)
Asteatotic eczema
Bruise, bruises, bruised
Diffuse erythema
Eczema
Fluctuant
Hematomas
Hydrated
Hyperpigmented rash
Intertriginous lesion
Keloid formation
Keratotic lesion
Macular rash
Maculopapular lesion
Mottled rash
Petechia
Pigmented lesion
Pink
Pruritic rash
Purpura
Raised lesion
Rash (red, macular)
Skin tags
Turgor (good)
Vasculitic lesions
Verruca vulgaris
Violaceous maculopapular lesion
Warm and dry
Wart
Wart-like
Without lesions
Dentures (upper, lower)
No trauma
Dopplerable left femoral pulse
Dorsalis pedis pulse
Lower extremity pulses all palpable
Noted bruit
Popliteal pulse
Pulses in upper extremities equal and symmetrical bilaterally
Alert and oriented times 3
Blood pressure
Blood pressure (sitting, standing)
Blood pressure with a manual cuff
Dizziness
Febrile/afebrile

Heart rate
Height
O2 saturation
Pulse (regular)
Pulse Ox
Pulse oximetry
Pulse rate (##/minute)
Respirations
Respiratory rate (regular, irregular, labored, not labored)
Saturation
Stable
Temperature (normal)
Weight