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MT Training > Terminology > Physical Examination symmetrical vocal cord motion temporomandibular joint throat is clear thrush TMs shiny and clear TM has a slight bulge and diffusion of cone of light tongue congestion tongue is dry tongue well-papillated tonsillar hypertrophy tonsils (tonsils are 3+ bilaterally) trichilemmoma trismus (no trismus) tympanic membranes uvula uvula is nonedematous uvula moves on phonation vermilion border visual acuity is _____ (dictated value, usually 20/20) visual field testing wax impaction Weber test NECK: anterior cervical lymphadenopathy bilateral bruits conducted from the aortic areas to both carotids. Brudzinski sign carotids are +2/4 carotids are full elevated JVP up to the angle of the jaw free of masses. goiter hepatojugular reflux or HJR (abbrev) JVD at 30 degrees, head up position. meningeal irritation meningeal signs meningismus neck brace. neck collar. neck is supple. no bruits. No carotid bruits. no cervical or supraclavicular lymph nodes. no jugular venous distention / No JVD. No JVP. Jugular venous pressure is not raised no JVD elevation. no lymphadenopathy or thyromegaly. no nodularity. no thyroid enlargement. nuchal rigidity nuchal spasm shotty lymph nodes (sounds "shoddy" but its shotty) trachea central trachea midline tender nodes venous distention at 45 degrees
HEART OR CARDIOVASCULAR:
A2 louder than P2 apical impulse apical murmur audible murmurs grade 1/6 or 2/6 or 3/6 systolic murmur. irregularly irregular rhythm loud P2 loud S3 gallop no ectopy no extra heart sounds no friction rub no heave or thrill no MR, no AI no precordial heave no S3 or S4 appreciated pericardial knock PMI is at the fifth intercostal space. PMI is at the fourth intercostal space. PMI is diffuse. PMI is hyperdynamic. PMI is not displaced. PMI. Point of maximal impulse. prosthetic click/sound Regular rate and rhythm. RRR. RSR S1 normal intensity, S2 single. S1, S2, S3, S4. S2 snapping sound with mild mitral insufficiency soft 2/6 or 3/6 or 1/6 systolic murmur along the left sternal border. soft systolic murmur. without murmur, gallop, rub or click.
CHEST: barrel chest expansion was symmetric midline sternotomy scar pigeon chest
LUNGS OR PULMONARY: accessory muscles of respiration adventitious sounds costophrenic angles crackles, wheezes, rhonchi. crepitant rales CTA (clear to auscultation) diminished breath sounds. E to A changes equal breath sounds good bilateral air entry. good breath sounds. good air exchange hyperresonant increased AP diameter inspiratory, expiratory. lung fields. Lungs are clear to A&P. Lungs are clear to auscultation and percussion. no retraction normal AP diameter pleural rub unlabored breathing vesicular breath sounds
ABDOMEN: all 4 quadrants appendectomy scar ascites ballottable Bowel sounds are active. cesarean section/hysterectomy scar seen. diffuse direct tenderness epigastric bruit fluid wave hyperactive bowel sounds. hypoactive bowel sounds. liver and spleen not palpable. liver is palpable McBurney's point Murphy's sign No guarding, rebound, hepatosplenomegaly. No masses. No hernias. No organomegaly or masses. Normoactive bowel sounds. Obese, bulky. PEG tube in place. peristalsis Positive bowel sounds. protuberant. renal angles scaphoid abdomen scars from previous surgery seen scars of surgery. soft, flat, nontender, nondistended stoma is patent
EXTREMITIES OR MUSCULOSKELETAL: 1+ or 2+ edema. above-knee amputation anatomic snuffbox ankle dorsiflexion ankle edema. anterior drawer sign Apley grind test Apley's test arc of motion ballotable patella balls of feet beats of clonus below-knee amputation brachial pulses are 1-2+ bunion calcaneal cuboid calf tenderness capillary refill CCE (cyanosis, clubbing or edema) Charcot foot. claudication clonus clubfoot. "clunk" test for tib-fib Cram test dependent edema DJD (degenerative joint disease) Dorsalis pedis and posterior tibial pulses. DP and PT pulses. drop-arm test for rotator cuff tear DTRs are 2+. DTRs are brisk. DTRs are symmetric. DTRs are trace. flexion contracture flexor digitorum footdrop functional hallux limitus genu valgum/genu varum golfer's elbow test good joint range of motion without bony deformities gravity drawer test grip is full hallux valgus Hawkins test (Hawkins impingement sign) Heberden's nodes of osteoarthritis hip click (infant examination) Homans sign Hoover sign / test Lachman Ludington test McMurray's test Mild pedal edema / trace pedal edema. milking the knee Moves all 4 extremities well. Mulder sign Neer test (Neer impingement sign) neutral calcaneal stance
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