General Appearance
Normal statement
clinical description
findings
general observations
pallor
flushed
jaundiced
clammy
sweating
cyanosed
appearance
nutrition
obese
morbidly obese
well nourished
under nourished
cachectic
anorexic
self care
cleanliness
grooming
odor
state of dress
physique
thin
tall
short
normal weight for height
slightly overweight for height
slightly underweight for height
overweight for height
average height
posture
function
behavior
normal and appropriate
mood description
unusual behavior details
speech
involuntary movements
handedness
left handed
right handed
smell
smells of alcohol
smells of ketones
specific smell
name
description
body site
degree
obvious abnormality on inspection
Vital Signs
blood pressure
data
any event
data
systolic
diastolic
mean arterial pressure
pulse pressure
comment
state
position
standing
sitting
reclining
lying flat
lying with lateral tilt
confounding factors
exertion
exercise intensity
description
intensity
low intensity
medium intensity
high intensity
flat out
measured
phase
at rest
during exertion
post exertion
sleep status
alert and awake
sleeping
tilt
24 hour average
data
comment
systolic
diastolic
mean arterial pressure
pulse pressure
state
tilt
position
lying with lateral tilt
standing
sitting
reclining
lying flat
confounding factors
exertion
phase
at rest
during exertion
post exertion
exercise intensity
description
intensity
low intensity
medium intensity
high intensity
flat out
measured
sleep status
sleeping
alert and awake
postural change
state
tilt
position
lying with lateral tilt
standing
sitting
reclining
lying flat
confounding factors
exertion
phase
at rest
during exertion
post exertion
exercise intensity
description
intensity
low intensity
medium intensity
high intensity
flat out
measured
sleep status
sleeping
alert and awake
data
comment
systolic
diastolic
mean arterial pressure
pulse pressure
protocol
cuff size
adult
large adult
pediatric / child
adult thigh
neonatal
infant
small adult
location
location of measurement
right arm
left arm
right thigh
left thigh
right wrist
left wrist
right ankle
left ankle
finger
toe
intraarterial
specific location
method
auscultation
palpatation
machine
invasive
mean arterial pressure formula
diastolic endpoint
phase IV
phase V
device
Body mass index
quantity (body mass index)
protocol
method
direct entry
automatic calculation
formula
body weight
weight
comment
state of dress
lightly clothed / underwear
naked
fully clothed including shoes
diaper / nappy
confounding factors
height/length
height/length
comment
position
lying down
standing
body temperature
data (temperature)
state
body exposure
naked
reduced clothing / bedding
appropriate clothing / bedding
increased clothing / bedding
environmental conditions
exertion
menstrual cycle
description of thermal stress
protocol
site of measurement
mouth
ear canal
axillia
rectum
nasopharynx
urinary bladder
intravascular
skin
vagina
oesophagus
inguinal skin crease
device
pulse
data
description
rate
rate
description
sinus rhythm
tachycardia
bradycardia
mixed tachycardia and bradycardia
rhythm
regular
irregular
irregularly irregular
bidgeminy
tridgeminy
occasional mixed beats
frequent missed beats
sinus rhythm
volume
large/full
normal
low/small
half
quarter
character
description
characteristics
bounding
thready
normal
slow-rising
water-hammer
collapsing
bisferiens
paradoxical
number of missed beats
pulse deficit
deficit
sites
ulnar artery
brachial artery
dorsalis pedis
tibialis posterior
radial artery
apex of the heart
carotid artery
femoral artery
popliteal
protocol
device
location of measurement
respirations
data
rate
rhythm
regular
irregular
depth
normal
shallow
deep
variable
descriptiono
abnormal respiratory pattern
state
ambient oxygen
confounding factors
exertion
examination
musculoskeletal exam
Joint examination findings
movement
general movement
description
relative range of movement
no movement
severe restriction
moderate restriction
minor restriction
full range of movement
associated pain
none
mild
moderate
severe
extreme
specific movement
type of movement
active movement
passive movement
movement
flexion
inversion
rotation
opening
closing
extension
abduction
adduction
internal rotation
external rotation
supination
pronation
eversion
description
arc of movement
angle or plane measured in degrees
relative range of movement
no movement
severe restriction
moderate restriction
minor restriction
full range of movement
associated pain
none
mild
moderate
severe
extreme
abnormal movement
ligament testing
name
movement or stress
finding
normal
lax
subluxing
palpatation
Tenderness
depth of palpatation
superficial
deep
Degree
absent
mild
moderate
marked
extreme
Category
superficial tenderness
deep tenderness
rebound tenderness
tenderness
rigidity
Body Site
Temperature
cold
cool
normal
warm
hot
Guarding
Degree
not present
mild
moderate
gross
Nature
voluntary
involuntary
uncertain
localized palpatation
Body site
Deformity
Cough impulse
true
false
surface/border
site description
consistency
hard/rigid
firm
soft
boggy
indents
features
smooth
craggy
irregular
nodular
crepitus present
true
false
locking of joint present
true
false
effusion
present
true
false
description
degree
Absent
mild
moderate
large
comparison to the other side
specific test
name of test
outcome of test
comments
(other exam details)
inspection
color description
deformity
location
description
shape or distribution
description
symmetrical
true
false
contour
overlying skin or surface
surrounds
edge
description
definition
well defined
moderately defined
poorly defined
translucent
true
false
muscle wasting
involved muscle group
description
other detail
drawing
examination of bone
name of bone
normal statement
clinical description
findings
details
abnormal findings
location
clinical description
breach of bone integrity
angulation present
crepitus present
image
examination of joints bones and muscles of:
head and neck
spine, ribs and pelvis
right upper extremity
left upper extremity
right lower extremity
left lower extremity
General physical exam
eyes
pupils
normal statements
findings
side
details
size
left
right
both eyes
direct light reflex present
consensual pupillary light reflex present
shape
pupillary accommodation reflex
speed of pupillary response
sluggish
normal
brisk
fundoscopic examination of the eyes
clinical description
side
details
red reflex
lens
optic disc
papilloedema
macula
retinal arteries
retinal veins
'Cotton Wool' artefacts
retinal background
vitreous
visualisation
ease of visualisation
fully visualised
partially visualised
not visualised
comment
ears, nose, mouth, and throat
examination of nose
normal statements
examination normal
clinical description
findings
inspection
external
clinical description
detail
nares
nares patent?
description
nasal breathing?
internal
clinical description
nasal septum
description
septal haematoma
detail
nasal mucosa
description
detail
turbinates
description
detail
discharge
description
details
palpation
clinical description
details
ear examination
normal statements
both ears normal
left ear normal
right ear normal
clinical description
lateral findings
side
left
right
physical
external ear
inspection
normal statements
external ear normal
pinna normal
external auditory canal normal
clinical description
findings
color description
location
anatomical area
pinna
external auditory canal
description
shape or destribution
description
Hypoplasia
atresia
bat
symmetrical
contour
overlying skin or surface
surrounds
edge
description
definition
well defined
moderately defined
poorly defined
translucent
operative scars
detail
drawing
palpatation
normal statements
normal
probably normal
no abnormality detected
soft
no tenderness
no masses
no foreign bodies
no hernias
clinical description
findings
part of the ear palpatated
auricle
mastoid
external meatus
other sites
tenderness
depth of palpation
superficial
deep
degree
absent
mild
moderate
moderate
marked
extreme
category
superficial tenderness
deep tenderness
rebound tenderness
tenderness
rigidity
other site
temperature
cold
cool
normal
warm
hot
guarding
degree
not present
mild
moderate
gross
nature
voluntary
involuntary
uncertain
localized palpation
cough impulse
surface/border
site description
consistency
hard/rigid
firm
soft
boggy
indents
features
smooth
craggy
irregular
nodular
detail
auditory canal
inspection
normal statements
ear canal normal
no foreign body
clinical description
findings
color description
location
shape or distribution
description
symmetrical
contour
overlying skin or surface
surrounds
edge
description
definition
well defined
moderately defined
poorly defined
translucent
foreign body
present
name/identification
description
presence of wax
discharge
present
detail
detail
tympanic membrane
inspection
findings
color description
location
shape or distribution
description
symmetrical
surface
no evidence of inflammation
evidence of inflammation
surrounds
edge
description
definition
well defined
moderately defined
poorly defined
translucent
true
false
adequacy of view
specific appearance
clinical description
light reflex present
contour
retraction
air/fluid level visible
scarring
description of scarring
evidence of atrophy
evidence of typanosclerosis
clinical description
ventilation tube
perforation
detail
normal statements
tympanic membrane normal
clinical description
functional
whisper test
rinne test
detail
central findings
functional
weber test
examination of the mouth
normal statements
clinical description
findings
detail
lips
clinical description
details
angle of mouth
details
clinical description
hard palate
clinical description
soft palate
flexible and mobile
gag response
description of swallowing
clinical description
uvula
deviation
none
deviation to right
deviation to left
clinical description
tonsillar fossa
tonsils present
relative size
absent
reduced in size
expected size
enlarged
grossly enlarged
clinical description
pharynx
clinical description
tongue
details
clinical description
neck
general examination
examination of thyroid
normal statements
clinical description
findings
inspection
visible abnormality
exam details
palpation
mobile on swallowing
left lateral lobe
right lateral lobe
isthmus
detail
respiratory
examination of the chest
normal statements
clinical description
findings
trachea
midline
deviated to the left
deviated to the right
apex beat
visible
palpatation
palpable
maximal location
breathing
description
type
diaphragmatic breathing
thoracic breathing
effort
normal breathing effort
mild increase in effort
moderate increased effort
major increased effort
signs of increased effort
sign
intercostal recession
sternal recession
rib retraction
suprasternal recession
subcostal recession
using accessory muscles
paradoxical movement (flail chest)
cardiovascular
postural edema
normal statements
object
clinical findings
clinical description
edema
character
description
pitting
extent
degree
comments
ascultation of the chest
normal statements
clear
normal second heart sound
no bronchial breathing
no amophoric breathing
normal vocal resonance
no abnormal added sounds
no rhonchi
no wheeze
no crepitations
no crackles
two hear sounds, no bruits
two heart sounds, no murmurs
two normal heart sounds
normal first heart sound
no murmur
no bruit
normal bowel sounds
no abnormality detected
clinical description
findings
heart sounds and bruits
first heart sound
volume
splitting
no splitting
physiological splitting
fixed splitting
paradoxical splitting
exaggerated splitting
clinical description
second heart sound
volume
splitting
exaggerated splitting
no splitting
physiological splitting
fixed splitting
paradoxical splitting
clinical description
Added heart sound
specific sound
opening snap
ejection click
pericardial rub
third heart sound
fourth heart sound
prosthetic valve sound
gallop rythm
phase of heart cycle
continuous
systolic
diastolic
pan-systolic
pan-diastolic
early systolic
mid-systolic
late systolic
early diastolic
mid-diastolic
late diastolic
volume
clinical description
bruits
maximal location
radiation
grading
character
pitch
phase of heart cycle
late diastolic
continuous
systolic
diastolic
pan-systolic
pan-diastolic
early systolic
mid-systolic
late systolic
early diastolic
mid-diastolic
clinical description
lung
area
region
phase of respiratory cycle
inspiratory
expiratory
early inspiratory
late inspiratory
early expiratory
late expiratory
findings
clinical description
Bowel sounds
specific findings
absent bowel sounds
decreased bowel sounds
increased bowel sounds
tinkling bowel sounds
clinical description
Vessel bruit
vessel name
maximal location
description
other sounds
description
maximal location
localised auscultation
site or region
chest (breasts)
gastrointestinal
abdominal exam
normal statements
clinical description
findings
abdominal wall
description
exam details
abdominal region
region
left upper quadrant
epigastrium
right upper quadrant
right loin
central/peri-umbilical
right iliac fossa
left iliac fossa
exam details
description
abdomen contents
exam details
organs
liver
exam details
dimensions
mass
palpation
percussion
relative position
size
description
spleen
exam details
size
dimensions
mass
palpation
percussion
relative position
description
kidney
exam details
size
dimensions
mass
palpation
percussion
relative position
description
bowel
exam details
size
dimensions
mass
palpation
percussion
relative position
description
description
detail
rectal
genitourna (male)
Gentournary (female)
lymphatic
examination of lymph nodes
normal statement
lymph node group
findings
size
individual nodes
node name
description
musculoskeletal
neurologic
tendon babinski reflexes
biceps
left
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
right
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
triceps
left
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
right
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
supinator
left
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
right
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
knee
left
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
right
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
ankle
left
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
right
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
babinski response
left
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
right
reflex not evident
reflex possibly present - markedly reduce amplitude
reflex present but reduced amplitude
reflex normal
reflex increased
reflex markedly increased
cranial nerve
normal statements
normal sense of smell
first cranial nerve normal
normal oculomotor movements
full range of ocular movements
normal cranial nerve examination
cranial nerves - no abnormality detected
second cranial nerve normal
normal corneal reflex
pupils equal and reactive to light and accomodation
findings
clinical description
first cranial nerve
odor tested
result
correctly identified
incorrectly identified
comment
second cranial nerve
fundoscopic examination
right
left
visual field testing
clinical description
third, fourth and sixth cranial nerves
fith cranial nerve
abnormal corneal reflex
sensory examination findings
clinical description
motor examination findings
seventh cranial nerve
normal statements
eyebrow elevation
forehead wrinkling
frowning
tightly closed eyes
showing teeth
whistling
puff out cheeks
smile
abnormal findings
abnormal statements
smile
eyebrow elevation
forehead wrinkling
frowning
tightly closed eyes
showing teeth
whistling
puff out cheeks
level of lesion
upper motor neuron
lower motor neuron
clinical description
eighth cranial nerve
hearing test results
vestibular testing results
clinical description
ninth and tenth cranial nerves
eleventh cranial nerve
clinical description
twelfth cranial nerve
tongue inspection
psychiatric
Skin
normal statements
clinical description
findings
method
direct visualisation
wood's lamp
dermatoscope
color description
location
shape or distribution
description
symmetrical
contour
surface
thickness
thickened
normal
thinned/atrophic
surrounds
pigmentation
edge
description
definition
well defined
moderately defined
poorly defined
translucent
detail
inspection of scalp
Skin findings
method
direct visualisation
wood's lamp
dermatoscope
color description
location
shape or distribution
description
symmetrical
contour
surface
thickness
thickened
normal
thinned/atrophic
surrounds
pigmentation
edge
description
definition
well defined
moderately defined
poorly defined
translucent
detail
normal statements
clinical description
hair
clinical description
color
distribution of hair
thickness of hair
Neck, nodes
examination of thyroid
normal statements
clinical description
findings
inspection
visible abnormality
exam details
palpation
mobile on swallowing
left lateral lobe
right lateral lobe
isthmus
detail
general examination