medical scribe physical exam (normal to abnormal)

general/constitutional normal

no acute distress (NAD)

well developed, well nourished

alert

general/constitutional abnormal

mild/moderate/severe distress (due to pain)

cachectic/emaciated/malnourished

somnolent, obtunded, unresponsive

head normal

atraumatic/ normocephalic (AT/NC)

head abnormal

any signs of trauma

sinus tenderness

angioedema

eyes normal

pupils equal, round, reactive to light (PEERL)

extraoccular movements intact (EOMI)

sclerae are anicteric

normal conjunctiva

eyes abnormal

Anisocoria (unequal pupils)

EOM entrapment

Scleral icterus

Pale conjunctiva (Anemia)

Conjunctiva; injection (conjunctivitis)

ears normal

tympanic membranes (TMs) normal

ears abnormal

TM erythema

TM bulging

TM dullness

TM obscured by cerumen

Nose normal

normal nares

singular- naris

plural- nares

nose abnormal

epistaxis

rhinorrhea

boggy turbinates (swollen inner nose)

septal hematoma

mouth and throat normal

moist mucous membrane

oropharynx (OP) normal

normal dentition

mouth and throat abnormal

dry mucous membrane (DMM)

pharyngeal erythema, tonsillar exudate, tonsillar hypertrophy

edentulous, dental caries

signs of PTA (peritonsillar abscess)

uvula shift

tonsillar asymmetry

neck and cervical spine normal

supple

neck and cervical spine abnormal

nuchal rigidity, meningismus, limited ROM

thyromegaly

jugular venous distension (JVD)

carotid bruit

cervical lymphadenopathy (swollen lymph nodes)

vertebral points vs. paraspinal tenderness

cardiovascular normal

regular rate

regular rhythm

heart sounds normal

abnormal cardiovascular

tachycardia (>100bpm)

bradycardia (<60 bpm)

irregularly irregular rhythm

murmur

gallop

rub

extrasystoles (extra beats)

cv contradiction regular rate

tachycardia (>100bpm)

bradycardia (<60 bpm)

cv contradiction regular rhythm

irregularly irregular rhythm

cv contradiction heard sounds normal

irregularly irregular rhythm

murmur

gallop

rub

extrasystoles (extra beats)

perfusion

radial pulse

carotid pulse

femoral pulse

dorsalis pedis (DP) pulse

posterior tibialis (PT) pulse

perfusion normal

pulses equal and symmetric

capillary refill less than 2 seconds

perfusion abnormal

unequal pulses

delayed capillary refill

pulses grading scale

0-absent

1+ = barely palpable

2+ = easily palpable

3+ = full

4+ = bounding/aneurysmal

pulmonary normal

1.no respiratory distress

2.normal respiratory rate

3.normal effort

4.-

5.breath sounds clear and equal

pulmonary abnormal

1.mild/moderate/severe respiratory distress

2.tachypnea (sign of respiratory distress)

3.accessory muscle use (sign of respiratory distress)

4.diminished (quiet) breath sounds

5. wheezes (inspiratory or expiratory) rales(crackles) rhonchi

pulmonary contradictions no respiratory distress

1.mild/moderate/severe respiratory distress

2.tachypnea (sign of respiratory distress)

3.accessory muscle use (sign of respiratory distress)

pulmonary contradictions clear to auscultation bilaterally

4.diminished (quiet) breath sounds

5. wheezes (inspiratory or expiratory) rales(crackles) rhonchi

abdominal normal

soft

non-tender

no peritoneal signs

normal bowel sounds

non-distended

abdominal abnormal

rigid (involuntary guarding)

mild/moderate/severe tenderness

peritoneal signs (surgical abdomen): rebound tenderness, rigidity (involuntary guarding), voluntary guarding

absent/hypoactive/hyperactive bowel sounds

organomegaly (hepatomegaly or splenomegaly)

distended

positive murphy sign (gllbladder RUQ)

appendix (RLQ)

positive mcburney's point tenderness

positive psoas sign

positive rovsing's sign

rectal normal

heme negative

brown stool

-

-

good rectal tone

rectal abnormal

heme positive (Guaiac positive)

black/melanotic, bright red, dark red, green, yellow, white

hemorrhoids (internal, external, thromboses)

rectal prolapse

decreased rectal tone (spinal cord injury)

female genital normal

1.normal external genetalia

2.normal bimanial exam

3.normal speculum exam

cervical os is closed

no blood or discharge

female genital abnormal

1.adenxal tenderness or mass

2. cervical motion tenderness (CMT)

uterine tenderness

3. cervical os is open blood in the vaginal vault, malodorous/thick white discharge

male genital normal

1. Circumcised or Uncircumcised

2. Normal Genital Exam

male genital abnormal

1. -

2. Testicular tenderness

Epididymal Tenderness

Testicular edema

Testicular mass

Urethral Discharge

Inguinal hernia

MUSCULOSKELETAL/EXTREMITIES normal

1. non-tender

2. full ROM (range of motion)

3. Distal CSMT (circulation, sensory,

motor, tendon) intact

4.-

5.-

MUSCULOSKELETAL/EXTREMITIES abnormal

1.Bony tenderness (fracture)

Soft tissue tenderness (contusion)

Calf tenderness (DVT)

2. Decreased ROM 2° pain

3. Pulse/Sensory/Motor deficits

Tendon Laxity

4. Pitting pedal edema (Trace to 4+)

5. Palpable cords/Homan's sign (DVT)

back normal

1. Non-tender thoracic and lumbar spine

back abnormal

1. Paraspinal tenderness (muscular)

Vertebral Point tenderness (spinal injury)

2.Midline deformities/step-offs

3.CVA tenderness

skin normal

1. Warm (normal temperature)

2. dry

3. normal color

4. no rashes

skin abnormal

1. Cool to touch

Hot to touch

2. Diaphoretic

3. Jaundice

Cyanotic

Pallor

4. Urticaria (hives)

Petechiae/Purpura

skin infection

normal: no sings of infection

abnormal:

Erythema

Calor (increased warmth)

Induration (cellulitis)

Fluctuant (abscess)

Purulent drainage

Lymphangitis

skin trauma

normal : Atraumatic

Intact

abnormal:

Ecchymosis

Contusion

Abrasion

Laceration

(size in cm)

Skin tear

Avulsion

neurological normal

1. alert

2. oriented x4

3. normal speech

4. nonfocal neuro exam

neurological abnormal

1. Somnolent

2. Disoriented to (person, place, time, or situation)

3. Aphasia (Expressive or Receptive)

Dysarthria

4. Any abnormal findings

neuro normal motor and sensation

1. Motor Strength 5/5 and symmetric

2.Sensation intact

neuro abnormal motor and sensation

1. Extremity weakness (see chart below)

Pronator Drift

2. Hypoesthesia (decreased sensation)

Numbness (absent sensation)

chart for motor and sensation

5/5 = Normal strength

4/5 = Very mildly weak

3/5 = Unable to overcome resistance

2/5 = Unable to overcome gravity

1/5 = Slight contraction, no movement

0/5 = Flaccid, limp

neuro deep tendon reflex (DTRs)

0 = Absent

1+ = Hypoactive

2+ = Normal

3+ = Increased

4+ = Unsustained clonus

neuro babinski

normal: Downgoing toes

abnormal: Upgoing toes

cranial neuro exam normal

1.Visual field intact

2.PERRL

3. EOMI

4.Tongue midline

5.Normal gag reflex

6.Facial symmetry

7.Facial sensation intact

8. Normal shoulder shrug

cranial neuro abnormal

1.Visual field loss

2.Unequal pupils (anisocoria)

3.EOM palsy, Rightward/Leftward gaze

4. Tongue deviation

5. Decreased gag reflex

6. Facial droop, Ptosis

7. Hypoesthesia, Numbness

8. Unequal shoulder shrug

neuro cerebellar exam normal

1. Normal gait

2. No nystagmus

3. Normal finger-to-nose, Normal heel-to-shin

5. Negative Romberg's

6. Normal RAM (Rapid Alternating Movements)

7. No tremor

neuro cerebellar exam abnormal