Physical Exam  (American jargon) TO: Brit jargon

Friday June 16

  (....EXAM DETAILS  on separate, linked pages)

This is a XX year old man  (or woman) , who looks about (younger or older than) his (her) stated age. He appears comfortable ( restless, pale, fatigued, agitated, in acute distress, discheveled, in severe pain, diaphoretic), cooperative (uninterested, belligerent, combative, intoxicated etc ) and is oriented x3 (is disoriented,  in which of the three spheres as to his person, time and place).

The patient is well developed, (short, miniature, large framed, tall) well nourished ( thin, anorexic, obese, grossly overweight, cachectic, ematiated).
Height, weight

 

VITAL SIGNS are:

Temperature  oral  (rectal,)  XX C  (F) , Pulse XX / min, regular (irregular, irregularly irregular, bounding, thin, faint, thready, frequent extra beats),
Respiration XX/min, smooth (labored, prolonged expiratory (inspiratory) phase, prominent stridor, croupy, ).
BP XXX / XX mmHg.

SKIN dry (sweaty, diaphoretic, scaling, ) , normal color, (icteric, bronz, few/frequent spider nevi, bruises) no leasions apparent.

HEAD

Normocephalic, (microcephalic, hydrocephalic) no evidence of trauma (describe as necessary. ) , no tenderness (tenderness over frontal and maxillary sinuses )

FACE normal (edematous, cyanotic) color, ( yellow waxy deposits on eyelids, butterfly rash on nose and cheeks, multiple waxy brown leasions a temporal skin ) no lesions no tenderness (non-/pigmented mole, nevus, raised, non-pigmented ulcerated leasion (size) on R/L nostril)

MOUTH lips are of normal color, (pale, cyanotic, cherry red, swollen,  cracked lips) oral mucous membrane non remarkable (dry, pale, injected, petechial hemorrhages, covered with exudate, foul smelling, white flaky exudate, aphtous spots, Koplik spots)

TONGUE normal, moist (dry, shrunken, beefy red, swollen, covered with yellow/white exudate, deviates to R/L side)

TEETH normal / in good repair (number missing, in poor repair, neglected, multiple fillings, partial/full dentures , removable / fixed )

GINGIVA normal (swollen, bleeding, neglected)

THROAT tonsils absent / normal (enlarged size, slightly / markedly enlarged, injected, flaming red, covered with exudate, multiple vesicles, multiple purulent crypts), uvula in midline (swollen, hyperaemic, split ), pharynx clear, normal color / not inflamed (covered with exudate, postnasal drip, injected, markedly swollen erythematous)

NOSE 

no obstruction, discharge or bleeding ( airway appears blocked, partial onstruction, sonorous breathing, bleeding from the nostril, discharge (color, character) )

EYES

Eyelids normal (yellow deposits bilatearl, upper/lower eyelids, yellow discharge)

PERRRLA, (Pupils Round, Regular,React to Light and Accomodation)
(Pupils are uneven, pinpoint, slugish reaction to light, do not react to light), sclera normal (injected, icteric) vision grossly normal, EOM
(ExtraOcular Movements) unrestricted, no nystagmus.

EARS

Pinna no deformity (deformity from surgical resection, cup ear, loop ear deformity, ulcerating leasion), ear canals clear (obstructed with wax), TM normal (tympanic membranes) (bright light reflexion, shiny, injected, bulging, perforated, discharge -color, character-)

 

NECK

free movement, no stiffness, no swelling, next veins flat,(restricted movement, stiff neck, veins distented in supine position, liver reflex positive) no masses, (mass -location consistency fixation-, lymph nodes palpable bilateral supraclavicular area) thyroid negative (thyroid diffusely enlarged bilateraly, firm peanut size fixed non tender mass lower pole R thyroid), trachea in midline (trachea deviated to R/L)

 

CHEST

Normal shape (barrel chest, markedly increased AP diameter, emphysematous, funnel chest (pectus excavatum), pidgeon chest (pectus curinatum), scoliosis, kyphosis), normal respiratory excursion both sides (assymetric chest excursion R/L side restricted, diaphragm fixed on the R/L) No surgical scars

(R/L thoracotomy scar, anterior midline scar)

Both lungs are clear to percussion no hyperresonance  (R/L sided dullness posteriorly ) ,

Normal vesicular breath sounds  entire chest bilateraly by auscultation (bilateral fine rales both sides inferiorly) no rales or ronchi on inspiration or expiration (course rales both chest upon inspiration, whistling sound on expiration, worse on R than on the L) no pleural rub  

LUNG EXAM DETAILS  

BREASTS

 Normal by inspection and palpation, (gynecomastia, masses (location, size)  dimpling,  discharge? implants Y/N ) no nipple deformity, no palpable masses  

BREAST EXAM DETAILS

HEART

PMI (Point of Maximal Impact, apex) not visible (if visible location) , apex palpable at the midclavicular line in the fifth interspace, (apex palpable X FB (fingerbreaths) lateral to MC line, palpable thrill at apex)

Heart sounds are normal, ( (jól ékelt szivhangok???)  split S1, S2) no murmurs, (Gr I./IV systolic/diastolic murmur, soft, blowing murmur, radiating into carotids) no rub (faint rub audible over entire precordium) 

CARDIAC EXAM DETAILS

 

ABDOMEN

No surgical scars ( well healed surgical scar RLQ, well defined caput medusae, ), flat (obese, distended, ) , soft (protected by guarding, boardlike) , nontender (RLQ, RUQ, LLQ tendernes, rebound tendernes RLQ) , no organs (liver palpable X FB below costal margin, spleen enlarged by percussion, ) or masses (large soft mass palpable in RL Quadrant,) , palpable. No fluid by percussion (evidence of free fluid, fluid shift)

Bowel sounds normal (BS absent, BS hypoactive, hyperactive, high tinkling,  )

No bruit, no hernias  ( mid abdominal bruit, umbilical / inquinal hernia R/L, incisional hernia )
No CVA (CostoVertebral Angle) tenderness (R/L tenderness, )
Murphy, McBurney signs negative

ABDOMINAL EXAM DETAILS

GENITALS

Normal female,   (pelvic exam deferred at this time )

Normal male external genitals   (penis infantile, R testicle atrophic, 5mm painless ulcer on glans, marked hydrocele, varicocele L/R testicle, )

 

NEUROLOGICAL

Oriented X 3  ( unable to tell day or time)

Cranial nerves intact  (double vision, visual field defect, nystagmus, anosmia, R/L facial nerve paresys or paralysis, hoarseness, tongue deviation )

Speach normal (dysphagia, aphasia )

Sensory exam and motor function intact  (decreased sensation in R ulnar nerve in hand, paresys or paralysis, muscle weakness,  ...)

Cerebellar function intact  (jerky fine tremor, intentional, unintentional tremor  )

Gate normal  (weers to the R with closed eyes, ataxia, wide gate, )

DTR.s active and symmetrical   (slugish R knee jerk, absent R Achilles  )

No pathological reflexes or signs  (Plantar reflex (Babinsky) (up, positive), Kernig sign positive, Brudzinski positive )

NEUROLOGICAL EXAM DETAILS

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LYMPH NODES

None palpable  ( describe location, (axillary, inquinal, cervical, postauricular, supraclavicular, occipital),   size (pea size, peanut size, walnut size, eggsize)  number, consistency ( solid, soft), mobility (freely mobile, fixed), painful )

MUSCULOSKELETAL

Muscle power is normal, (weak, painful, masses palpable) no deformities (congenital, aquired extremity deformity, kyphosis, scoliosis), all joints full range of motion (limitation of motion,  -active, -passive,  joint enlargement, temperature, palpable fluid in joint, tenderness, erythema, muscle atrophy / symmetry,  )

 

PERIFERAL VASCULAR

Periferal pulses normal and symmetrical (carotid, radial,  femoral, dorsalis pedis, tibialis posteror,  palpable or not or week, abdominal arteries. bruit?,  Stasis? Edema? Varicosities (location, extent, inflammation, skin color, pain)? Ulceration?  Calf tenderness? Homan's sign?)

 

RECTAL EXAM

Sphincter tone normal (sphincter loose,  )

No hemorrhoids, (moderate internal hemorrhoids, external hem.. bleeding, inflamed, ulcerated, painful, thrombosed ) no palpable rectal masses, (polyp, soft diffuse velvety mass,  constrictive  ring like mass (at X cm, at X o'clock) )

Prostate normal size ( enlarged x2), and consistency, (soft, boggy, firm mass in ... lobe, tenderness,  )

Stool normal color, (clay colored, blood stained, tarry) quaiac negative for occult blood  (1 -- 4 plus )

THE END

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dischevelt = zilált

belligerent = veszekedő

ematiated = összeaszott