Case Notes ED injury assessment - Family History

ED injury assessment

History

Allergy

Medications

Past medical history

Last oral intake

Events leading to this injury with details

Patient condition

Alone

With friend/relative

Referred from another hospital

Clinical features

Vomiting

Seizures

Drowsiness

Dizziness

LOC

Syncope

Inability to bear weight

Headache

Blurred vision

Personality change

Abnormal movements

Pain

Site

Choose Site

Bleeding

Site

Choose Site

Swelling

Site

Choose Site

Injury/burn/poisoning assessment

Traumas

Stairs fall

Fall down

RTA

Pedestrian injury

Fall from chair

Fall on outstretched hand

Weight bearing trauma

Blunt trauma

Penetrating trauma

How high

Minimal height

High fall

Height

Poisoning

Overdose drug ingestion

Accidental drug ingestion

Poisoning

Smoke inhalation

Burns and similar

Burn

Fire or explosion

Electrical/lightning injury

Heat injury

Cold injury(Frostbite)

Cold injury(Accidental hypothermia)

Others

Sports injury

Violence

Drowning

Suicide attempt

Near-hanging

Animal/Insect bites

Min

Hours

Days

Weeks

Months

Years

Ago

Type

Blunt trauma

Penetrating trauma

Weight bearing

Forced injury

Sudden movement

Site

Choose Site

Load

Specify Site

Direction of impact

Front

Back

Right Side

Left Side

Developed

Pain

Redness

Tenderness

Swelling

Deformity

LOC

Position of Trauma

Upper Limb

Flexed

Extended

Pronated

Supinated

Twisting

Lower Limb

Flexion

Extended

Inversion

Eversion

Twisting

Deformation

Poisoning

Animal/Insect bites

Accidental drug ingestion

Overdose drug ingestion

Symptoms

LOC

Vomiting

Seizures

Cyanosis

Chocking

GI irritation symptoms

Penetrating trauma

Knife

Metal

Glass

Gunshot

Violence

Guns

Knives

Sports injury

RTA

Seatbelt injury

Airbag

Dashboard injury

Ejected from vehicle

Vehicle rollover

Whiplash injury

Place in the vehicle

Driver

Front passenger

Back passenger

Speed of the car

Low speed

High speed

Did any medical condition of the driver cause the RTA?

Pedestrian injury

Speed of the car

Did any medical condition of the driver cause the RTA?

Pedestrian injury

Speed of the car

Primary survey

General Assessment

Consciousness

Alert

Drowsy

Lethargic

Stupor

Coma

Fluctuating

Hepatic encephalopathy

Responsiveness

Responsive

Unresponsive

Activity

Hyperactive

Active

Inactive

GCS

Orientation

Oriented

Disoriented to time

Disoriented to place

Disoriented to person

Cooperativity

Cooperative

Uncooperative

Refused

Examination

Investigation

Management

Others

Irritable

Restless

Agitation

Apathy

Anxiety

Confusion

Lucid interval

Abnormal behavior

Spontaneous speech

Absent speech

Normal respiratory movement

Absent respiratory movement

Elevated ICP Features

Headache

Decreased mental abilities

Blurred vision

Papilledema

Shock signs

Pallor

Cold skin

sweating

Tachycardia

Tachypnea

Hypotension

Oliguria

Confusion

Irritability

Airway

Findings

Head

Jaw

Face

Nose

Airway

Neck

injury

Swallowed tongue

FB ingestion

Missing teeth

Mouth bleeding

Vomitus

Epistaxis

Aspiration

Cervical spine

Normal ROM

Restricted ROM

Respiration

SOB

Hyperventilation

Cannot complete a sentence

accessory muscle use

Nasal flaring

Pursed lips breathing

Kussmaul respiration

Suprasternal recession

Supraclavicular recession

Infraclavicular recession

Intercostal recession

Subcostal recession

Paradoxical respiration

Audible breathing sounds

Silent airway

Wheeze

Stridor

Snoring

Gurgling

Grunting

Resuscitation

Patented by C-collar

Head tilt

Chin lift

Jaw thrust

Nasopharyngeal airway

Oropharyngeal airway

Endotracheal intubation

Cricothyroidotomy

Tracheostomy

O2 mask

Suction catheter

Semi-prone position

Diagnosis

Airway obstruction

Skull base fracture

Breathing

Findings

Spontaneous breathing

Paradoxical respiration

Jugular venous distention

Flail chest

Subcutaneous (Surgical) emphysema

Sternal tenderness

Localized rib tenderness

Generalized rib tenderness

Respiratory distress

Cyanosis

Apnea

Trachea

Centralized trachea

Right tracheal deviation

Left tracheal deviation

Ribs number

Right

Left

Bilatera

Respiratory movements

Normal

Shallow

Absent

Thoracic

Abdominal

Symmetry

Symmetrical respiratory movements

Asymmetrical respiratory movements

Tactile Vocal Fremitus Add New

Normal

Increased

Decreased

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

Lung Field

Percussion note Add New

Resonant

Hyperresonant

Stony dull

Dull

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

Lung Field

Air entry Add New

Normal

Reduced

Absent

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

Lung Field

Normal

Increased

Decreased

Inspiratory

Expiratory

both

Phases

Breath sound

Vesicular

Harsh vesicular

Bronchial

Bronchovesicular

Vocal resonance Add New

Speech

Normal (Not heard)

Clearly heard

muffled

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

Lung Field

Resuscitation

Closed circuit O2 mask

Needle decompression

Chest tube

Thoracotomy

Mouth-mouth breathing

Diagnosis

Pneumothorax

Open Pneumothorax

Tension Pneumothorax

Hemothorax

Lung contusion

Pleural effusion

Consolidation

Rib fracture

Sternal fracture

Circulation

Bleeding wound site

Choose Site

Bleeding character

Continuous

Pulsating

Color

Bright red

Dark

Grade

Mild

Moderate

Severe

Clinical signs of bleeding

Pale

Anxious

Sweaty

Rapid thready pulse

Hypotension

Tachypnea

CRT >2 seconds

Headache

Visual impairment

Dizziness

Coma

Sunken eyes

Dry mucous membranes

Jugular venous distention

Cold clammy extremity

Dry skin

skin tenting (reduced skin turgor)

Reduced urine OP

Other bleeding signs

Weakness

Chest pain

SOB

Chest dullness

Abdominal tenderness

Abdominal distention

Vomiting

Hematuria

Joint pain

Joint swelling

Decreased ROM

Resuscitation

Wound dressing

Splint

IV Line crystalloids

IV Line blood transfusion

Chest tube

Pericardiocentesis

Log-roll movement

Direct/Proximal pressure over bleeding site

Pneumatic cuff

Vascular clamp

Tourniquet

Sternotomy

Clam-shell thoracotomy

Left lateral thoracotomy

How long?

min

hrs

Complicated by

Nerve damage

Muscle damage

Diagnosis

Bleeding wound

Internal bleeding

Cardiac arrest

Hypovolemic shock

Cardiogenic shock

Neurogenic shock

Cardiac tamponade

Cardiac contusion

Disability

Alert

Responding to voice

Responding to pain

Unresponsive

Obeys commands

Failure to obey commands

Seizures

Paralysis/Partial paralysis

Quadriplegia

Quadriparesis

Paraplegia

Paraparesis

Right Hemiplegia

Left Hemiplegia

Right Hemiparesis

Left Hemiparesis

Right upper limb monoplegia

Left upper limb monoplegia

Right lower limb monoplegia

Left lower limb monoplegia

Pupils

Shape

Round

Oval

Regular

Irregular

Size

Normal size

Constricted

Dilated

Symmetry

Symmetrical

Asymmetrical

Pupillary light reflex

Present

Absent

Symmetrical reaction

Asymmetrical reaction

Consensual light reflex

Present

Absent

Environment

Resuscitation

Avoided hypothermia

Clothes removed

Covered with gown and warm blanket

Log-roll movement

Secondary survey

Physical Examination

General

Head

Eye

Ear

Nose

Mouth

Neck

Chest

Cardiovascular

Abdomen

Pelvis

Obs & Gyn

Back

Upper Limb

Lower Limb

Nervous System

Mental status

Pediatrics

Important Negative Findings

General

Mental state

Consciousness

Alert

Drowsy

Lethargic

Stupor

Coma

Fluctuating

Hepatic encephalopathy

Responsiveness

Responsive

Unresponsive

Activity

Hyperactive

Active

Inactive

GCS

Orientation

Oriented

Disoriented to time

Disoriented to place

Disoriented to person

Cooperativity

Cooperative

Uncooperative

Refused

Examination

Investigation

Management

Others

Irritable

Restless

Agitation

Apathy

Anxiety

Confusion

Appearance

Well

Sick

Toxic

Distressed

In pain

Tired

Body built

Cachectic

Undernourished

Thin

Average

Obese

Morbid obese

Stature

Tall

Average for age

Short

Power

Well-nourished

Frail

Others

Generalized obesity

Truncal obesity

Coloration

Pallor

Cyanosis

Jaundice

Plethora

Bronze

Gray

Red

Yellow

Pale-lemon

Decubitus(Posture) Add New

Fixed

Mobile

Lying on right side

Lying on left side

Flexing

Extending

Neck

Shoulder

Elbow

Wrist

Fingers

Hip

Knee

Ankle

Toes

Spine

Dehydration signs

Cold extremity

Sunken eyes

Dry skin

skin tenting (reduced skin turgor)

Dry mucous membranes

CRT >2 seconds

Reduced urine OP

Dizziness

Tachycardia

Dysmorphism

Growth

Limbs too short for the head & trunk

Trunk & head too short for the limbs

Arm span exceeds height

Reduced upper body segment to lower segment ratio

Failure to develop secondary sexual characters(hair distribution, voice growth, libido)

Growth deficiency

Head

Anterior fontanelle(Flat)

Anterior fontanelle(sunken)

Anterior fontanelle(bulging)

Frontal swelling

Occipital swelling

Parietal swelling

Temporal swelling

Size

Microcephaly

Macrocephaly

Shape

Holoprosencephaly

Brachycephaly(Short-headed)

Dolichocephaly(Long-headed)

Plagiocephaly(Oblique-headed)

Head molding

Flat occiput

Prominent occiput

Signs

Hydranencephaly

Hydrocephalus

Caput succedaneum

Encephalocele

Cephalohematoma

Subgaleal hematoma

Aplasia cutis congenita

Anencephaly

Sutures

Craniosynostosis

Overriding cranial sutures

Separated cranial sutures with obvious gap

Face

Round face

Small face

Long face

Micrognathia

Macrognathia

Receding chin

Maxillary prominence

mandible protrusion

Mandibular malocclusion

Frontal bossing

Bulging forehead

Sloping forehead

Asymmetric facial features

Flat midface

Elfin facies

Facial swelling

Eye

Anophthalmia

Microphthalmia

Macrophthalmia

Epicanthal folds

Upslanting palpebral fissure

Downslanting palpebral fissure

Sunset eye appearance

Eyelid ptosis

Eyelid coloboma

iris coloboma(Keyhole/Cat-eye appearance)

Buphthalmos(Congenital glaucoma)

Brushfield spots

Hypertelorism

Hypotelorism

Short palpebral fissure

Long palpebral fissure

Eyebrows meeting in midline

Telecanthus

Almond-shaped eyes

Cataracts

Cyclopia(Single eye)

Nose

Small nose

Enlarged nose

Flattened nasal bridge

Prominent nasal bridge

Blocked right nostril

Blocked left nostril

Beaked nose

Nasal septum extending below alae nasi

Cebocephaly(Single nostril)

Broad nasal root

Well-defined philtrum

Ear

Small ears

Large ears

Low-set ears

Everted ear

Posteriorly rotated

Malformed

Mouth

Separation of teeth

Protruding upper teeth

Protruding lower teeth

Dental malocclusion

High arched palate

Cleft palate

Cleft lip

Macroglossia

Glossoptosis(Posterior tongue displacement)

Ankyloglossia(Tongue tie)

Small mouth

Wide smile

Thin lips

Epstein's pearls

Epulis

Tent-shaped mouth

Ranula

Neck

Shortened neck

Wide neck

Webbed neck

Neck mass

Neck asymmetry

Goiter

Chest

Chest asymmetry

Scheuermann kyphosis

Widely-spaced nipples(Shield-like chest)

Pectus excavatum

Pectus carinatum

Gynecomastia

Accessory nipple

Premature thelarche

Neonatal mastitis

Harrison's sulcus

Rachitic rosary

Pectoralis major hypoplasia

Short sternum

Spine & Back

Scoliosis

Thoracic kyphosis

Anencephaly

Spina bifida occulta

Meningocele

Myelomeningocele

Sacral dimple

Atlantoaxial instability

Sacral pigmented patches

Sacral agenesis

Sacrococcygeal teratoma

Sacrococcygeal pit

Sprengel deformity of the scapula

Increased distance between vertebrae

Abdomen/Pelvis

Delayed umbilical cord stump separation

Umbilical granuloma

Bleeding umbilicus

Periumbilical erythema

Umbilical hernia

Inguinal hernia

Omphalocele(Exomphalos)

Gastroschisis

Olive-like mass

Ectopia vesicae(Bladder exstrophy)

Ambiguous genitalia

Penile enlargement

Phallus

Empty scrotum

Virilizing genitalia

Closed labia

Prominent labia minora

Enlarged clitoris

Lumps along labia

Rectal

Rectal atresia/stenosis

Imperforated anus

Absent anus

Rectal prolapse

Male

Undescended testis

Ectopic testis

Retractile testis

Macro-orchidism

Small genitalia

Unilateral hydrocele

Bilateral hydrocele

Scrotal swelling

Scrotal hematoma

Chordee(Abnormal penile curvature)

Hypospadias(Glandular)

Hypospadias(Coronal)

Hypospadias(Midshaft)

Hypospadias(Penoscrotal)

Hypospadias(Scrotal)

Hypospadias(Perineal)

Epispadias

hypogonadism

Testicular atrophy

Female

Vaginal discharge

Vaginal bleeding

Hypoplasia of labia minora

Upper limb Add New

Right

Left

Bilateral

Short upper limb

Long upper limb

Short digits

Long digits

Clinodactyly (Curved digits)

Digits overlapping digits

Oligodactyly(few digits)

Polydactyly(many digits)

Syndactyly(Fused digits)

Dactylitis(Swelling entire digit)

Flexed digits

Finger aplasia

Hypoplastic nail

Small hands

Limb reduction defect

Missing limb

Limb length discrepancy

Radioulnar synostosis

Radial aplasia

Short metacarpal bones

Broad hands

Large fleshy hands

Transverse palmar crease

Swelling of hands

Increased carrying angle

Arachnodactyly

Joint laxity

Joint restricted ROM

Joint contracture

Lower limb Add New

Right

Left

Bilateral

Short lower limb

Long lower limb

Short digits

Clinodactyly (Curved digits)

Digits overlapping digits

Oligodactyly(few digits)

Polydactyly(many digits)

Syndactyly(Fused digits)

Dactylitis(Swelling entire digit)

Toe aplasia

Limb reduction defect

Missing limb

Limb length discrepancy

Rocker-bottom feet

Hypoplastic nail

Wide feet

Narrow feet

Small feet

Swelling of feet

Bowing of legs

Tibial bowing

Flat foot

Joint laxity

Joint restricted ROM

Joint contracture

Hindfoot deformity

Environment

Respiratory

O2 Mask

Nasal cannula

Chest tube

Tracheostomy

Laryngoscopy

Endotracheal tube

Cpap/Bipap

Mechanical Ventilation

Pigtail catheter

Cardiovascular

Central venous catheter

Pulmonary artery catheter

24hr Holter monitor

IV Line

Arterial Line

Port-A-Cath

Arteriovenous fistula

Pacemaker

Cardiopulmonary monitor

IVC Filter

Hemodialysis catheter

GI Tract

Nasogastric tube

24hrs Ph Monitoring Probe of Esophagus

PEG Tube

Ascitic drain

Peritoneal dialysis

Rectal tube

Stoma

Duodenostomy

Jejunostomy

ileostomy

Colostomy

Loop colostomy

Type

Spout

Afferent and efferent limbs

Terminal

Neurological

EEG Video Monitoring

Intracranial Pressure Monitor

Cranial Nerve Monitoring

External Ventricular Drain

Ventriculoperitoneal Shunt

Genitourinary

Condom catheter

Urethral catheter

Nephrostomy

Permicatheter

Skin & Musculoskeletal

Site

Choose Site

Finding

Cast

Slab

Bracing

External fixation

Skin traction

Skeletal traction

Cervical traction

Lumbar traction

Dressing

Graft

Flap

Palpable surgical instruments

vacuum assisted dressing

Character

Dry and clean

Soaked

Changed

Unclean

Wound

Wound debrided and closed

Wound discharge

Infected wound

Wound dehiscence

Clean wound

Sutured wound

Unsutured wound

Upper limb specific

Short Arm Splinting

Posterior elbow Splint

Posterior Long Arm Splint

Radial Gutter slab

Ulnar Gutter slab

Thumb Spica Splint

Sugar-Tong Splint

Lower limb specific

Hip Spica

Posterior Long Leg Splint

Pavlik Harness Placement

Others

Mattress Compression

Pneumatic Compression

Restraint

Procedure sites abnormalities

Functioning

Non-functioning

Redness

Warmth

Tenderness

Pain

Discharge

Hygiene

Good oral hygiene

Good body hygiene

Poor oral hygiene

Poor body hygiene

Respiration

SOB

Hyperventilation

Cannot complete a sentence

accessory muscle use

Nasal flaring

Pursed lips breathing

Kussmaul respiration

Suprasternal recession

Supraclavicular recession

Infraclavicular recession

Intercostal recession

Subcostal recession

Paradoxical respiration

Audible wheezes

Audible stridor

Audible breathing sounds

Silent airway

Wheeze

Stridor

Snoring

Gurgling

Grunting

Skin

Flushed

Collapsed

Cold

Warm

Normal temperature

Dry

Clammy

Normal hydration status

Speech

Normal

Slurred

Hoarseness

Broca’s(Motor) aphasia

Wernick’s(Sensory) aphasia

Global aphasia

Stertor

Heavy

Husky

Deep

Nasal quality

Nasal escape

Fatiguing speech

Vowel-based and lack clear articulation

Low-volume speech

speech inability due to procedure (tracheostomy-intubation)

Smells

Halitosis

Fetor hepaticus

Ketones

Alcohol

Uremia

Faecal

Fetid

Mobility

Normal

Mobilizing freely on bed only

Restricted mobilization

Immobilization

Bedridden

Wheel chair

Use of walking aids

Inability to bear weight

Symptoms observed with patient

Vital signs

Pulse Add New

Right

Left

Bilateral

Site

Radial

Ulnar

Brachial

Carotid

Pedal

Posterior tibial

Popliteal

Femoral

Rate

Beats/min

Rhythm

Regular

Irregular

Regular irregular

irregularly irregular

Volume

Normal

Absent

Weak

Bounding(Aneurysmal)

Character

Collapsing pulse(Water-hummer pulse)

Slow-rising pulse

Pulsus bisferiens

Pulsus alternans

Pulsus paradoxus

Symmetry

Symmetrical

Asymmetrical

Bruit

Carotid

Aortic

Femoral

Popliteal

Renal

Subclavian

Other findings

Radio-radial delay

Radio-femoral delay

Blood pressure Add New

mmHg

Normal

Hypertension

Hypotension

Character

Elevated pulse pressure

Low pulse pressure

Postural hypotension

Method

BP Cuff

indwelling intra-arterial catheter

Posture

Standing

Sitting

Supine

Respiratory rate

Rate

Breaths/min

Breathing pattern

Regular

Irregular

Deep

Shallow

Hyperventilation

Apnea

Air hunger

Cheyne-Stokes breathing

Kussmaul breathing

Paradoxical breathing

Temperature

°C

°F

Hypothermia

Fever

Malignant hyperthermia

Route

Oral

Ear

Axilla

Rectal

SaO2

Room air

O2 mask

Head

Increased hat size

Mastoid bruising

Temporal arteries tenderness

Spider nevi

Abnormal head posture

Temporal wasting

Face

Malar rash(Butterfly rash)

Puffiness

Plethora

Flushing

Facial swelling

Parotid swelling

Chloasma

Frontal sinus tenderness

Maxillary sinus tenderness

Chvostek sign

Painful parotid swelling

Painless parotid swelling

Atrophy

Hypertrophy

Wasting

Facial spasm

Facial fasciculation

Facial pain

Facial tenderness

Facial weakness

Facial shape

Earthy look

Lion face

Adenoid face

Expressionless face

Coarse facial features

Facial asymmetry

Facial drooping

Eye Add New

Right

Left

Bilateral

Appearance

Exophthalmos

Enophthalmos

Red eye

Dry eye

Watery eye

Tissue loss

Horner's Syndrome

Sunset eye

Periorbital edema

Yellow crusting

Eye discharge

Wearing glasses

Microphthalmia

Macrophthalmia

Foreign body

Eye tenderness

Amount

Large

Moderate

small

Color

Green

Yellow

Gray

Content

Clear

Bloody

Purulent

Consistency

Watery

Mucoid

Sticky

Odor

Offensive

Non-offensive

Ocular alignment

Squint

Upward

Downward

Medial

Lateral

Gaze Palsy

Movement

Normal

Restricted

Painful

Fixed position

Intranuclear ophthalmoplegia

All directions

upward

downward

medial

lateral

superomedial

Inferomedial

superolateral

Inferolateral

movement

Oculocephalic reflex(Doll's eye movements)

Present (Normal)

Absent

Accommodation reflex

Normal

Impaired

Schirmer's test

>15mm (Normal)

5-15mm (Equivocal)

< 5mm (Abnormal)

Nystagmus

Direction

Horizontal

Vertical

Rotatory

Multidirectional

Gaze

Upward

Downward

Medial

Lateral

Type

Jerky

Pendular

Optokinetic

Character

Associated with vertigo

Vision

Visual agnosia

Macropsia

Micropsia

Double vision

On which gaze

Upward

Downward

Medial

Lateral

superomedial

Inferomedial

superolateral

Inferolateral

Visual field defects

Loss of vision

Left upper quadrantanopia

Left lower quadrantanopia

Right upper quadrantanopia

Right lower quadrantanopia

Left homonymous hemianopia

Right homonymous hemianopia

Left homonymous hemianopia with macular sparing

Right homonymous hemianopia with macular sparing

Bitemporal hemianopia

Central scotoma

Horizontal scotoma

Arcuate scotoma

Ring scotoma

Visual Acuity

06/

Can see top letter on Snellen chart at

meters

Can count finger correctly at

meters

20/

Can’t see top letter on Snellen chart at

meters

Can’t count finger correctly at

meters

Can see hand movement

Can’t see hand movement

Can see light

Can’t see light

Color vision

Color blindness

Color

Impaired color vision

Refractive Error

Hyperopia(Farsightedness)

Myopia(Nearsightedness)

Astigmatism

Presbyopia

Lacrimal apparatus

Dacryocystitis

Swollen lacrimal gland

Eyelid

Edema

Eyelid drooping (Ptosis)

Xanthelasma

Lid lag

Lid retraction

Blepharitis

Blepharospasm

Eyelid coloboma

Entropion(inverted eyelid)

Ectropion(everted eyelid)

Stye

Chalazion

Conjunctiva

Conjunctivitis

Subconjunctival hemorrhage

Conjunctival pallor

Redness

Chemosis (Conjunctival edema)

Petechiae

Pterygium

Pingueculae

Sclera

Blue

Red

Jaundice

Episcleritis

Scleritis

Scleromalacia

Cornea

Corneal arcus

Corneal ulcer

Corneal erosion

Cloudy cornea

Corneal edema

Corneal opacity

Hazy cornea

Corneal calcification (Band keratopathy)

Circumciliary injection (Redness around corneal limbus)

Limbic calcification

Enlarged cornea

Kayser-Fleischer ring

Pupils

Shape

Round

Oval

Regular

Irregular

Size

Normal size

Constricted

Dilated

Symmetry

Symmetrical

Asymmetrical

Pupillary light reflex

Present

Absent

Symmetrical reaction

Asymmetrical reaction

Consensual light reflex

Present

Absent

Red reflex

Present

Absent

Other finding

Leukocoria

Iris

Anterior uveitis (iritis)

Corneal arcus

New vessel formation

Brushfield's spots

Lisch nodules

Iris coloboma

Lens

Cataract

Peripheral cortical cataract

Posterior subcapsular cataract

Nuclear sclerosis cataract

Lens thickening

Lens opacity

Lens coloboma

Pseudophakia

Aphakia

Upward lens dislocation

Downward lens dislocation

Medial lens dislocation

Lateral lens dislocation

Ear

Right

Left

Bilateral

Inspection

Pinna

Hematoma

Tenderness

Tragus tenderness

Hearing aid

Peripheral cyanosis

Small ears

Large ears

Low-set ears

Abnormal shape

Ear deformity

Basal cell cancer

Squamous cell cancer

Subcutaneous tophi

Swollen

External auditory canal

Red

Discharge

Wax

Foreign body

Wide

Closed

Furunculosis

Exostosis

Rash

Tympanic membrane

Absent light reflex

Tympanosclerosis

Retraction pocket of pars tensa

Cholesteatoma

Effusion

Air-fluid level

Ventilation tube (Grommet)

Inflammation

Hemotympanum

Yellow

Red

Chalky white

Blue

Red streaks

White plaques

Perforation

Position

Upward

Downward

Medial

Lateral

Percentage

Tests

Hearing tests

Whispered voice test

Normal

Abnormal

If Abnormal, Cannot repeat whispered sound at approx

Weber’s test

Symmetrical sound in both ears

Sound heard louder in right ear

Sound heard louder in left ear

Rinne’s test

Normal (AC > BC)

BC > AC in right ear

BC > AC in left ear

Vestibular function tests

Turning test:

Normal

Turning toward the right side

Turning toward the left side

Nystagmus

Direction

Horizontal

Vertical

Rotatory

Multidirectional

Gaze

Upward

Downward

Medial

Lateral

Type

Jerky

Pendular

Optokinetic

Character

Associated with vertigo

Unterberger's test

Normal

Rotated to right side

Rotated to left side

Fistula test

Normal

Nystagmus

Vertigo

Impression

Conductive hearing loss

Sensorineural hearing loss

Eustachian tube dysfunction

Otitis externa

Otitis media

Nose

Appearance

Saddle nose deformity

Depressed nasal bridge

Small

Wide

Poorly developed bridge

Rhinophyma

Findings

Adenoid hypertrophy

Turbinate hypertrophy

deviated nasal septum to the right

deviated nasal septum to the left

Nasal septum perforation

Septal hematoma

infection

Adhesions

Nasal polyp

Nasal crusts

Dry nasal mucosa

Foreign body

Adenoid face

Clear nasal discharge

Purulent nasal discharge

Nasal congestion

Beaking of the nose

congested Little's area on right side

congested Little's area on left side

Mucosa

Dry

Moist

Pale

Red

Gray

Swollen

Nostrills

Patent

Blocked

Right

Left

Bilateral

Mouth

Lips

Stomatitis

Angular stomatitis

Central cyanosis

Lip swelling

Sore lips

Lip cracking

Tongue

Size

Macroglossia

Microglossia

Movements

Tremors

Fasciculation

Involuntary movements

Deviation

Weakness

Spastic tongue

Findings

Leukoplakia

Erythroplakia

Central cyanosis

Geographic tongue

Wasting

Aphthous ulcer

Sore tongue

Tenderness

Papillary atrophy

Covered by membrane

Submandibular duct discharge

Submandibular duct stone

Tight frenulum

Lingual goiter

Oral thrush

Ranula

Appearance

Dry

Moist

Glossitis

Excessive fissuring

Smooth red tongue

Atrophic glossitis (Smooth pale tongue)

Beefy raw appearance

Teeth Add New

Upper

Lower

incisor

Canine

Premolars

Molar

Teeth number

Dental caries

Teeth loss

Loose teeth

Dental abscess

Overcrowding

Abnormal dental alignment

Fitting well dentures

Poorly fitting dentures

Dental crown

Dental bridge

Bilirubin staining

Brown teeth

Yellow teeth

Gray teeth

Tobacco staining

Impacted teeth

Mandible swelling

Gums

Gingivitis

Bleeding

Enlargement

Firm

Spongy

Red line

Blue line

Buccal mucosa

Ulcer

Aphthous ulcer

Nodule

Stomatitis

Oral thrush

Buccal pigmentation

Koplik’s spots

Wickham's Striae

Parotid duct stone

Parotid duct discharge

Dry mouth

Hard palate

Stomatitis

High arched palate

Cleft palate

Aphthous ulcer

Torus palatinus

Palatal petechiae

Soft palate

Aphthous ulcer

Asymmetrical movement

Palatal petechiae

Uvula

Displaced to the right

Displaced to the left

Throat

Congested pharynx

Pus over pharynx

Pharyngitis

Aphthous ulcer

Exudative throat

Follicles

Retropharyngeal abscess

Parapharyngeal abscess

Tonsils

Changes

Tonsillitis

Swollen

Congestion

Asymmetry

Ulcer

Tenderness

Peritonsillar abscess

Mass

Membrane

True membrane

False membrane

White membrane

Gray membrane

Discharge

Exudate

Pus

Neck

Inspection

Short neck

Wide neck

Webbed neck

Jugular venous distention

Distended veins

Visible pulsation

Deformity

Spider nevi

Fasciculation

Spasm

Wasting

Hypertrophy

Weakness

Painful movement

Palpation

Tenderness

Stiffness

Limited range of motion

Cervical rib

Centralized trachea

Right tracheal deviation

Left tracheal deviation

Chest

Inspection

Respiratory movements

Normal

Shallow

Absent

Thoracic

Abdominal

Symmetry

Symmetrical respiratory movements

Asymmetrical respiratory movements

Chest deformity

Pectus carinatum

Pectus excavatum

Hyperinflated 'Barrel-shaped' chest

Other findings

Distended veins

Gynecomastia

Breast atrophy

Galactorrhea

Harrison's sulci

Scar

Spider nevi

Palpation

Chest expansion

Reduced chest expansion in the right

Reduced chest expansion in the left

Reduced chest expansion bilaterally

Tactile Vocal Fremitus Add New

Normal

Increased

Decreased

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Other findings

Centralized trachea

Right tracheal deviation

Left tracheal deviation

Tracheal tug

Flail chest

Subcutaneous (Surgical) emphysema

Localized rib tenderness

Generalized rib tenderness

in ribs number

Right

Left

Bilateral

Percussion note Add New

Resonant

Hyperresonant

Stony dull

Dull

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Auscultation

Air entry Add New

Normal

Reduced

Absent

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Normal

Increased

Decreased

Inspiratory

Expiratory

both

Phases

Breath sound

Vesicular

Harsh vesicular

Bronchial

Bronchovesicular

Vocal resonance Add New

Speech

Normal (Not heard)

Clearly heard

muffled

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Findings

Bronchophony

Whispered pectoriloquy

Egophony

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Added sounds

Crackles

Early

Mid

Late

Inspiratory

Expiratory

Biphasic

Fine

Coarse

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Clear after cough

Doesn’t clear after cough

Wheezes

Inspiratory

Expiratory

Biphasic

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Other added sounds

Pleural rub

Pleuro-pericardial rub

Pneumothorax click

Stridor

crunching sound (Hamman's sign)

Mid-expiratory squeak

in the

Right

Left

Bilateral

All

Upper

Middle

Lower

Basal

lung Field

Cardiovascular

Inspection

Visible cardiac pulsation

Palpation

Apex beat

Not displaced

Displaced downward and laterally

Character

Forceful

Tapping

Double beat

Other findings

Left parasternal heave

Thrill

in the

Right side of sternum

Left side of sternum

Apex

Neck

JVP

Normal

Raised

Pulsatile

Non-pulsatile

Abdominojugular reflex

Present

Absent

Height

Waveform

Giant 'a' wave

Giant ‘v' wave

Absent 'a' wave

‘cv' wave

Cannon waves

‘v' wave

Posture

45 degrees

Flat

Sitting

Sign

Kussmaul's sign

Auscultation

S1:

Normal

Muffled

Loud

Variable

Normal

Muffled

Loud

Muffled

Loud

Muffled

Loud

S2 splitting

Fixed

Variable

Reversed wide splitting

Regularity

Regular

Irregular

Added sounds Add New

Pericardial rub

Pleuro-pericardial rub

Opening snap

Ejection click

Mid-systolic click

Metallic heart sound

Crunching sound(Hamman's sign)

Site

Pulmonary

Tricuspid

Aortic

Mitral

Left axilla

Left infraclavicular

Interscapular

Left scapula

Carotid arteries

Right lower sternal border

Right midaxillary line

area

Murmur

Type

Pansystolic

Systolic ejection

Midsystolic

Late systolic

Early diastolic

Mid-diastolic

Late diastolic

Continuous machinery

Site

Pulmonary

Tricuspid

Aortic

Mitral

Left axilla

Left infraclavicular

Interscapular

Left scapula

Right midaxillary line

Right lower sternal border

Carotid arteries

area

Radiation

Pulmonary

Tricuspid

Aortic

Mitral

Left axilla

Left infraclavicular

Interscapular

Left scapula

Right midaxillary line

Right lower sternal border

Carotid arteries

area

Character

High-pitched

Low-pitched

Harsh

Blowing

Rumbling

Musical

Squeaking

Whooping

Honking

Rasping

Grunting

Grade

1- 6

Abdomen Choose site first when applicable for inspection and superficial palpation findings only

Site Add New

Generalized

Rt Side of the abdomen

Lt Side of the abdomen

Upper abdomen

Central abdomen

Lower abdomen

Rt Loin

RHC

Rt Flank

Rt iliac F

Rt groin

Epigastrium

Periumbilical

Suprapubic

LHC

Lt Flank

Lt iliac F

Lt groin

Lt Loin

RUQ

RLQ

LUQ

LLQ

Inspection

Shape

Flat

Scaphoid

Symmetrical

Asymmetrical

Findings

Abdominal distention

Distended veins

Visible pulsations

Visible peristalsis

Visible bowel loops

Hernia

Mass

Caput medusa

Sister Mary Joseph nodules

Abdominal stria

Bruise

Linea nigra

Divarcation of recti

Spider nevi

Abdominal mottling

Scratch marks

Frozen pelvis(hard rigid feel of pelvic organs)

Umbilicus

Inverted

Everted

Flat

Sunken

Distended

Blue

Umbilical hernia

Signs

Cullen's sign

Grey-Turner's sign

Pointing sign

Superficial palpation

Soft

Hard

Lax

Rigid

Tenderness

Rebound tenderness

Hard feacal masses

Palpable AAA

Voluntary guarding

Involuntary guarding

Variable guarding

Board-like rigidity

Deep palpation

Liver

Shrunken

Hepatomegaly

enlarged

cm below costal margin

fingerbreadth below costal margin

Mild

Moderate

Marked

Enlargement

Surface

Smooth

Irregular

Edge

Smooth

Irregular

Consistency

Soft

Hard

Character

Pulsatile

Tender

Hepatojugular reflex

Raised JVP

Spleen

Splenomegaly

enlarged

cm below costal margin

Tip

Moderate

Marked

Enlargement

Gallbladder

Palpable

Impalpable

Tender

Ascites

Shifting dullness

Positive

Negative

Fluid thrill

Positive

Negative

Kidney Add New

Right

Left

Bilateral

Palpable

Impalpable

in the

Rt Flank

Rt iliac F

Lt Flank

Lt iliac F

Size

Mild enlargement

Moderate enlargement

Filling a whole side of abdomen

Surface

Smooth

irregular

Consistency

Soft

Firm

Hard

Character

Tender

Non-tender

Renal angle tenderness

Urinary bladder

Distended

Signs

Hepatobiliary

Murphey sign

Courvoisier’s sign

Pointing sign

GI Tract

Mcburney’s sign

Psoas sign

Obturator sign

Rovsing’s sign

iliopsoas sign

Auscultation

Bowel sounds

Normal

Absent

Reduced

Increased

Loud

Tinkling

High-pitched

Low-pitched

Bowel sounds over right lung

Bowel sounds over left lung

Bruit

Aortic

Renal artery

Mesenteric

Liver

Other findings

Friction rub of the liver

Friction rub of the spleen

Succussion splash

Pelvis

Scrotum

Hydrocele

Varicocele

Ulcer

Tenderness

Testis Add New

Right

Left

Bilateral

Enlarged

Absent

Tenderness

Pain

Torsion

Atrophy

Retracted

Ectopic perineal testis

Ectopic groin testis

Ectopic thigh testis

Ectopic penile testis

Penis

Circinate balanitis

Penile plaques

Urethra

Epispadias

Discharge

Blood from external urethral meatus

Bladder incontinence

Hypospadias

Glandular

Coronal

Midshaft

Penoscrotal

Scrotal

Perineal

Digital rectal

Pain

Tenderness

Lateralized tenderness(Pelvic peritonitis)

Ballooning

Anal fissure

Fistula

Ulcer

Hematoma

Rectal stenosis

Bowel incontinence

Mucosal irregularity

Frozen pelvis(hard rigid feel of pelvic organs)

Sphincter tone(Weak)

Sphincter tone(Spasm)

Rectal bleeding (Bright red blood)

Rectal bleeding (Dark red blood)

Lump at

o’clock position

Tender

Nontender

% of rectal circumference involved

Distance from anus

Impression

Polyp

Abscess

Villous adenoma

Carcinoma

Hemorrhoids

Rectal prolapse

Piles

Tender

Reduced spontaneously

Reduced manually

Irreducible

Thrombosed

Strangulated

Rectal prolapse

Distance from anus

Prostate

Normal

Enlarged

Small

Tender

Nontender

Symmetric

Asymmetric

Surface

Smooth

Irregular

Nodular

Single nodule

Consistency

Rubbery

Firm

Hard

Stony hard

Boggy

Obliterated midline sulcus

High riding

Defined border

ill-defined border

Stool

Color

Pale

Dark

Tarry black

Matt black

Red blood

Silvery

Red

Content

Fresh blood

Clotted blood

Mucus

Pus

Non-bloody

blood

Consistency

Semisolid

Fatty/greasy

Watery

Floating

Loose

Rice

Ricewater

Hard

Odor

Offensive

Non-offensive

Obs & Gyn

Gynecological examination

External genitalia

Skin infection

Redness

Tenderness

Mass

Virilization

Clitoromegaly

Vulval discharge

Episiotomy scar

Scars

Rash

Bladder incontinence

Digital Vaginal

Mass

Polyp

Ulcer

Fistula

Bleeding

Leak

Tenderness

Vaginal tear

Vaginal rugae

Adnexal tenderness

Dryness

Prolapse

Cystocele

Urethrocele

Rectocele

Enterocele

Uterine prolapse

Uterine procidentia

Vault prolapse

Vaginal discharge

Color

Clear

White

Gray

Green

Yellow

Brown

Content

Pus

Blood

Consistency

Egg white-like

Thick

Thin

Curdy

Watery

Mucoid

Odor

Fishy

Malodorous

Uterus

Position

Anteverted

Retroverted

Anteflexed

Retroflexed

Normal size

Enlarged

Small

Contracted

Relaxed

Surface

Smooth

Irregular

Mobility

Mobile

Fixed

Other findings

Adnexal mass

Discomfort

Palpable fallopian tube

Uterine swelling

Uterine tenderness

Uterine rebound

CS Scar

Uterine guarding

Cervix

Cervical excitation

Ulcer

Polyp

Bleeding

Red

Softening

Bluish

Mass

Cervical motion tenderness

Obstetric examination

Single pregnancy

Twin pregnancy

twins

Lie

Longitudinal

Oblique

Transverse

Presentation

Cephalic

Vertex

Face

Brow

Chin

Sinciput(Forehead)

Shoulder

Arm

Trunk

Compound

Cord

Breech

Complete

Footling

Frank

Kneeling

Fetal movements

Present

Decreased

Absent

Amniotic fluid

Normal

Polyhydramnios

Oligohydramnios

Fetal heart sounds

Positive

Negative

Position

Digital Vaginal (Pregnancy)

Bleeding

Bloody show

Normal lochia

PPH

Membrane leak

SROM

PROM

PPROM

Prolonged ROM

AROM

Effacement

No effacement

Partial effacement

Full effacement

Cervix position

Posterior

Station

(Enter a number from -5 to +5)

Breast examination Add New

Right

Left

Bilateral

Accessory breast

Breast atrophy

Asymmetry

Breast engorgement

Irregular nodularity

Mammillary fistula

Areolar darkening

Skin dimpling

Skin indrawing

Peau d' orange

Axillary swelling

Axillary tenderness

Inflammation signs

Redness

Warmth

Tenderness

Pain

Swelling

Nipple

Accessory nipple

Inversion

Eczema

Nipple discharge color

Clear

Yellow

White

Green

Content

Blood

Pus

Galactorrhea

Back Add New

Tenderness over

irregularity over

Increased prominence over

vertebrae

Diffuse cervical spine tenderness

Diffuse thoracic spine tenderness

Diffuse lumbar spine tenderness

Diffuse sacral tenderness

Coccygeal tenderness

Paraspinal tenderness

Spinal cord signs

Difficult walking

Lower limb weakness

Neck pain

Difficult moving the neck

Decreased perianal sensation

Bowel incontinence

Bladder incontinence

Weak sphincter tone

Deformity

General

Loss of height

Dowager’s hump

Boggy swelling

Elevated scapula

Depressed scapula

Winged scapula

Cervical spine

Loss of cervical lordosis

increased cervical lordosis

Cervical flexion deformity

Lateral cervical flexion deformity

Thoracic spine

Rib hump

Gibbus

Increased thoracic kyphosis

Scoliosis

Kyphoscoliosis

Lumbar spine

Loss of lumbar lordosis

Increased lumbar lordosis

Scoliosis

Special tests

Lumbar spine and lumbosacral plexus

Schober's test

Positive: the distance between the two points increase by <5cm

Normal: the distance of the two points increases by 5 to >20 cm

Straight leg raise

Limited hip flexion

Pain elicited by ankle dorsiflexion

Pain elicited by cervical spine flexion

Pain relieved by knee flexion

N hip flexion (80-90degrees)

Tibial nerve stretch test

Pain elicited by tibial nerve pressure while the patient is flexing the hip and extending the knee in supine position

Negative

Femoral nerve stretch test

Pain felt while flexing the knee and extending the hip while the patient is prone

Negative

Flip test

While the patient is sitting with the knees and hips flexed to 90 degrees each, Upon extending the knee the patient lies flat due to pain

Negative

Joints

Cervical spine

Thoracic spine

Lumbar spine

Sacral spine

Coccyx

Sacroiliac

Lumbosacral

Sacrococcygeal

Inflammation signs

Redness

Warmth

Tenderness

Swelling

Consistency

Soft

Hard

Fluctuant

Impression

Bony

Soft tissue

Bursa

Effusion

Synovitis

Pain

Migratory

then to

At rest

Exacerbated by

Relieved by

Any movement

Flexion

Extension

Lateral flexion

Rotation

Head nodding

Painful surrounding structures including ligaments, bursae, muscles, bones, tendons

Skin overlying the joint

Peeling

Rash

scars

sinuses

Bruise

Muscle wasting

Feel

Crepitus

Instability

Joint locking

Deformity

Fixed

Reducible

Type

Flexion

Extension

Rotation

Abduction

Adduction

Dislocation

Posterior

Lateral

Medial

If e.g. anteromedial, choose both Anterior and Medial

Subluxation

Contracture

Flexion

Extension

Move

Weakness

Painful movement

Exacerbated by

Relieved by

Any movement

Flexion

Extension

Lateral flexion

Rotation

Head nodding

Stiffness

Morning stiffness

Inactivity stiffness

Restricted range of motion

Hypermobility

Other abnormal movement

Skeleton

Cervical vertebrae

Thoracic vertebrae

Lumbar vertebrae

Sacrum

Coccyx

Intervertebral disc

Cervical spine

Thoracic spine

Lumbar spine

Sacral spine

Sacroiliac

Lumbosacral

Sacrococcygeal

Pubic symphysis

Findings

Resting pain

Painful movement

Tenderness

Swelling

Consistency

Fragile

Stony hard

Soft

Thick

Weak

Muscles

Back

Spinal

Paraspinal

Inspection

Fasciculation

Contracture

Swelling

Spasm

Cramps

Twitching

Muscle bulk

Atrophy

Hypertrophy

Pseudohypertrophy

Wasting

Others

Pain

Tenderness

Stiffness

Weakness

Painful movement

Proximal muscle wasting

Distal muscle wasting

Nervous System

Higher cerebral function

Obeys commands

Dyslexia

Dyscalculia

Dysgraphia

Apraxia

Oculomotor apraxia

Buccofacial apraxia

Verbal apraxia

Motor apraxia

Sensory apraxia

Amnestic apraxia

Constructional apraxia

Dressing apraxia

Gait

Limping

Antalgic

Coxalgic

Stepping

Staggering

Festinant

Difficult tiptoe walking

Unsteadiness

impaired tandem gait(Heel-to-toe walking)

Sensory ataxia

Cerebellar ataxia

Scissoring (crouch)

Waddling (Trendelenburg)

Magnetic

Shuffling

Wide-Based

High-stepping

Foot drop

Abnormal movements Add New

Type

Tremors

Dystonia

Athetosis

Pseudoathetosis

Tics

Hemiballismus

Ballism

Sydenham’s Chorea

Chorea

Writhing

Torticollis

Anterocollis

Retrocollis

Myoclonic jerks

Twitching

Infantile spasm

Distribution

All limbs

Generalized

Right Face

Left Face

Right upper limb

Left upper limb

Right arm

Left arm

Right forearm

Left forearm

Right hand

Left hand

Right lower limb

Left lower limb

Right thigh

Left thigh

Right leg

left leg

Right foot

Left foot

Character

Resting

On movement

Impression

Physiological

Essential

Parkinsonism

Intention

Functional

Seizures type

Simple partial

Complex partial

Absence seizures

Tonic-clonic seizures

Tonic seizures

Clonic seizures

Atonic seizures

Power

Residual stroke weakness in

All limbs

Right upper limb

Right lower limb

Left upper limb

Left lower limb

Fatigable weakness

Weakness in

Walking

Climbing stairs

Getting up from chair

Raising arms above the head

Standing from squatting position

Sitting up from supine position

Raising leg while supine

Carrying

Combing hair

Pinch grip

Maintaining grip

gripping handles and bottles

Paralysis/Partial paralysis

Quadriplegia

Quadriparesis

Paraplegia

Paraparesis

Right Hemiplegia

Left Hemiplegia

Right Hemiparesis

Left Hemiparesis

Right upper limb monoplegia

Left upper limb monoplegia

Right lower limb monoplegia

Left lower limb monoplegia

Coordination

Normal

Heel to shin

Finger to nose

Rapid alternating movements

Sensory ataxia (Romberg's sign Positive)

Ataxia

Heel to shin

Finger to nose

Rapid alternating movements

Sensory ataxia (Romberg's sign Positive)

Slowed movement

Heel to shin

Finger to nose

Rapid alternating movements

Sensory ataxia (Romberg's sign Positive)

Primitive reflexes appearance

Palmar grasp reflex

Snout reflex

Palmomental reflex

Glabellar tap reflex

Parkinsonian features

Stooped posture

Shuffling gait

Loss of arm swing

Delayed initiation of walking

Short steps

Lead-pipe rigidity

Meningeal Signs

Neck stiffness

Kernig's sign

Brudzinski's sign

Cranial nerves Note that Right, Left and Bilateral here represent the clinical findings not the cranial nerve

Right

Left

Bilateral

Olfactory CNI

Loss of smell

Parosmia

Optic CNII

Visual field defects

Loss of vision

Left upper quadrantanopia

Left lower quadrantanopia

Right upper quadrantanopia

Right lower quadrantanopia

Left homonymous hemianopia

Right homonymous hemianopia

Left homonymous hemianopia with macular sparing

Right homonymous hemianopia with macular sparing

Bitemporal hemianopia

Central scotoma

Horizontal scotoma

Arcuate scotoma

Ring scotoma

Visual Acuity

06/

Can see top letter on Snellen chart at

meters

Can count finger correctly at

meters

20/

Can’t see top letter on Snellen chart at

meters

Can’t count finger correctly at

meters

Can see hand movement

Can’t see hand movement

Can see light

Can’t see light

Oculomotor CNIII

Down and out eye

Inability to adduct eye

Dilated pupil

Eyelid drooping (Ptosis)

Impaired accommodation reflex

Absent Pupillary light reflex

Absent Oculocephalic reflex(Doll's eye movements)

Trochlear CNIV

Adducted and elevated eye

Abducent CNVI

Loss of eye abduction

Adducted and down eye

Trigeminal CNV

Impaired corneal reflex

Weakness or wasting of temporalis muscle

Weakness or wasting of Masseter muscle

Increased jaw reflex

Jaw deviation

Loss of fine touch facial sensation

Loss of Pin-prick facial sensation

Numbness

Pain

Rash

Over

Ophthalmic division

Maxillary division

Mandibular division

Nasal Tickle test:

Positive(Normal)

Negative in right nostril

Negative in left nostril

Facial CNVII

Facial asymmetry

Facial drooping

Lack of facial expression

Involuntary facial movements

Facial numbness

Loss of forehead wrinkles

Asymmetrical forehead wrinkles

Loss of nasolabial folds

Inability to close the eye

Air leak when puffing the mouth

Baring of the teeth

Loss of taste sensation of anterior 2/3 of tongue

Mouth deviation

Drooped corner of the mouth

Tongue deviation

Hyperacusis

Synkinesis

Upper facial weakness

Lower facial weakness

Generalized facial weakness

Vestibulocochlear CNVIII

Hearing tests

Whispered voice test

Normal

Abnormal

if abnormal, Cannot repeat whispered sound at approx

Weber’s test:

Symmetrical sound in both ears

Sound heard louder in right ear

Sound heard louder in left ear

Rinne’s test

Normal (AC > BC)

BC > AC in right ear

BC > AC in left ear

Vestibular function tests

Turning test

Normal

Turning toward the right side

Turning toward the left side

Nystagmus

Direction

Horizontal

Vertical

Rotatory

Multidirectional

Gaze

Upward

Downward

Medial

Lateral

Type

Jerky

Pendular

Optokinetic

Character

Associated with vertigo

Unterberger's test

Normal

Rotated to right side

Rotated to left side

Fistula test

Normal

Nystagmus

Vertigo

Impression

Conductive hearing loss

Sensorineural hearing loss

Eustachian tube dysfunction

Otitis externa

Otitis media

Glossopharyngeal CNIX

Loss of gag reflex

Loss of taste sensation of posterior 1/3 of tongue

Loss of soft palate sensation

Dysphagia

Vagus CNX

Slurred speech

Hoarseness(RLN injury)

Bovine cough(RLN injury)

Soft palate deviation

Uvula deviation

Dysphagia

Impaired soft palate movement

Nasal regurgitation of fluids

Nasal air escape when the cheeks are puffed out

Accessory CNXI

Weakness of shrugging

Weakness of head turning

Displaced upper vertebral border of scapula away from spine and lower border towards it

Trapezius wasting

Trapezius hypertrophy

Sternomastoid wasting

Sternomastoid hypertrophy

Hypoglossal CNXII

Tongue wasting

Tongue fasciculation

Tongue deviation

Tongue weakness

Tongue involuntary movement

Spastic tongue

Slurred speech

Dysphagia

Chewing problems

Upper limb Add New

Right

Left

Bilateral

Clubbing

Fine tremors

Flapping tremors

Calcinosis

Distended veins

Tetany (Trousseau's sign)

Tetany (Carpopedal spasm)

Amputated

Prosthetic limb

Large fleshy hand

Thyroid acropachy

Delayed relaxation of grip

Hypertrophic pulmonary osteoarthropathy

Subcutaneous rheumatoid nodules

Janeway lesion

Osler's nodes

Peripheral cyanosis

Tobacco staining

Palmar erythema

Dupuytren's contracture

Gouty tophi

Xanthomata

DVT Signs

Swelling

Redness

Tenderness

Pain

Distended veins

Vascular

Well perfused

Pain

Pulseless

Pallor

Paresthesia

Paralysis

Cold

Collapsed veins

Bleeding

Normal CRT < 2sec

CRT > 2sec

Shortened limb

Hair loss

Dry gangrene

Wet gangrene

Gas gangrene

Allen test

Normal circulation

Abnormal circulation

Skin

Thick

Tight

Soft

Rough

Dry

Sweaty

Greasy

Clammy

Pigmented skin creases

Hand callosities

Venipuncture marks

Cyanotic mottled skin

Spider nevi

Temperature

Normal

Warm

Cold

Amputated

Partial hand (transcarpal)

Thumb

Index finger

Middle finger

Ring finger

Little finger

At the wrist (wrist disarticulation)

Below the elbow (transradial)

At the elbow (elbow disarticulation)

Above the elbow (transhumeral)

At the shoulder (shoulder disarticulation)

Above the shoulder (forequarter)

Stump

Dry

Clean

Discharge

Infected

Inflammation signs

Ischemia

Bleeding

Phantom pain

Phantom limb sensation

Depression

Nails

Leukonychia

Koilonychia

Psoriasis

Nail pitting

Nail ridging

Nail dystrophy

Nail dysplasia

Brittle nails

Splinter hemorrhage

Onycholysis

Onychomycosis

Fungal infection

Paronychia

Beau's lines

brown nail band

Muehrcke's lines

Dilated nailfold capillaries

Nail overgrowth

Color changes

Blue

Red

Brown

White

Yellow

Green

Musculoskeletal

Shoulder

Supraspinatus hyperalgesia

Frozen shoulder

Acromion tenderness

Coracoid tenderness

Scapular spine tenderness

Biceps tendon tenderness

Special tests

Empty can test(Jobe's test)

Pain on shoulder abduction, flexion and internal rotation

Negative

Painful arc

Pain from 120 to 60 degrees on active shoulder adduction of the fully abducted shoulder

Negative

Bicipital tendonitis

Pain on arm flexion against resistance

Negative

Neer test

Pain on shoulder flexion while the arm is pronated

Negative

Hawkins test

Pain on shoulder internal rotation when abducting the shoulder and flexing the elbow at 90 degrees

Negative

Cross-arm test

Pain at acromioclavicular joint while adducting the 90 degrees flexed shoulder

Negative

For the following Pain suggests tendonitis, Loss of power suggests tear:

Supraspinatus test

Pain on shoulder abduction initiation

Loss of power on shoulder abduction initiation

Negative

Infraspinatus test

Pain on shoulder external rotation against resistance

Loss of power on shoulder external rotation against resistance

Negative

Subscapularis test

Pain on shoulder internal rotation against resistance while hand is in the back

Loss of power on shoulder internal rotation against resistance while hand is in the back

Negative

Elbow

Medial epicondyle tenderness

Lateral epicondyle tenderness

Olecranon tenderness

Fluid-filled sac

Special tests

Tennis elbow

Pain at lateral epicondyle

Negative

Golfer’s elbow

Pain at medial epicondyle

Negative

Hand

Wrist tendon thickening

Wrist tendon tenderness

Wrist tendon crepitus

Raynauds phenomenon

Sclerodactyly

Bouchard's nodes

Heberden's nodes

Deformity

Swan neck

Ulnar deviation

Square hands

Boutonniere deformity

Anterior wrist displacement

Mallet finger

Trigger finger

Special tests

Prayer’s sign

inability to flatten the hands together

Normal hands flattening

Tinel’s sign

Pain/paresthesia upon tapping

Negative

Phalen's test

pain/paresthesia/tingling provoked

Negative

Reverse Phalen's test

pain/paresthesia/tingling provoked

Negative

Neuro

Tone

Increased

Decreased

Atonia

Spasticity

Flaccidity

Rigidity

Power

Weakness

Add New

Shoulder

Flexion

Extension

Abduction

Adduction

Grade

Elbow

Flexion

Extension

Grade

Wrist

Flexion

Extension

Grade

Fingers

Flexion

Extension

Abduction

Adduction

Grade

Thumb

Flexion

Extension

Abduction

Adduction

Grade

Pronator drift

After patient outstretches and supinates hands with eyes closed, one arm starts to pronate

Negative

Reflexes

Biceps(C5)

Increased

Normal

Decreased

Present only with reinforcement

Slow relaxing reflex

Grade

Brachioradialis(C6)

Increased

Normal

Decreased

Present only with reinforcement

Slow relaxing reflex

Grade

Triceps(C7)

Increased

Normal

Decreased

Present only with reinforcement

Slow relaxing reflex

Grade

Finger(C8)

Increased

Normal

Decreased

Present only with reinforcement

Slow relaxing reflex

Grade

Hoffmann's reflex

Positive (Thumb flexion elicited by flicking the distal phalanx of middle finger)

Negative

Abdominal reflex(T8-12)

Positive

Negative

Sensation Add New

Pain

Absent

Reduced

Increased

Temperature

Normal

Impaired

Touch

Normal

Impaired

Vibration

Normal

Impaired

Joint position

Normal

Impaired

Two-Point Discrimination

Normal

Impaired

Stereognosis

Normal

Impaired

Graphesthesia

Normal

Impaired

Choose distribution of any finding

Glove and stocking distribution

Nerve distribution

Dermatomes distribution

Rash along dermatome

Site

Right face

Left face

Right trunk

Left trunk

Right upper limb

Left upper limb

Right lower limb

Left lower limb

Abnormal sensation

Paresthesia

Tingling

Sensory loss

Decreased sensation

Increased sensation

Allodynia

Hyperalgesia

Nerve injury

Erb’s-Duchenne Palsy (C5, C6)

Adducted shoulder

Medially rotated shoulder

Extended elbow

Pronated forearm

Sensory loss on lateral side of forearm

Waiter hinting for a tip sign

Klumpke’s Palsy (C8, T1)

Hyperextension of MCP joints

Flexion of interphalangeal joints

Loss of abduction and adduction of fingers

Sensory loss on medial side of arm

Sensory loss on medial side of forearm

Claw hand

Ape hand

Long thoracic nerve

Winging of the scapula

Difficulty raising arm above the head (above 90°)

Axillary nerve

Impaired shoulder abduction

Flat shoulder (Deltoid wasting)

Sensory loss over deltoid

Radial nerve

Impaired elbow extension

Impaired wrist extension (Wrist drop)

Impaired fingers extension (Fingers drop)

Impaired forearm supination

Paresthesia over posterior surface of arm

Paresthesia over posterior surface of forearm

Paresthesia over lateral 2/3 of hand dorsum

Paresthesia over posterior surface of proximal phalanges of the lateral 3 ½ fingers

Median nerve

Adducted thumb

Laterally rotated thumb

Ape’s hand appearance

Thenar atrophy (Wasting)

Sensory loss on lateral 2/3 of the palm

Sensory loss on palmar surface of lateral 3 ½ fingers

Impaired forearm pronation

Impaired wrist flexion

Adducted wrist

Impaired flexion of MCP and interphalangeal joints of index and middle fingers

Impaired thumb flexion

Impaired thumb opposition

Carpal tunnel syndrome

Weak thenar muscles

Ape’s hand appearance

Paresthesia over palmar surface of lateral 3 ½ fingers

Intact sensation over lateral 2/3 of the palm

Ulnar nerve

Hyperextended MCP joints of 4th and 5th fingers

Flexed interphalangeal joints of 4th and 5th fingers

Partial claw hand appearance

Impaired thumb adduction

Impaired abduction and adduction of fingers

Hypothenar atrophy (Wasting)

Sensory loss on medial 1/3 of hand

Sensory loss on medial 1 ½ fingers

Abducted hand

Musculocutaneous nerve

Impaired elbow flexion

Impaired forearm supination

Sensory loss on lateral side of forearm

Suprascapular nerve

Impaired lateral rotation of shoulder

Impaired shoulder abduction between 0° - 15°

Joints

Shoulder

Acromioclavicular

Sternoclavicular

Elbow

Wrist

CMC

MCP

PIP

DIP

Thumb

Index finger

Middle finger

Ring finger

Little finger

Elbow

CMC of index finger

Inflammation signs

Redness

Warmth

Tenderness

Swelling

Consistency

Soft

Hard

Fluctuant

Impression

Bony

Soft tissue

Bursa

Effusion

Synovitis

Pain

Add New

Migratory

then to

At rest

Exacerbated by

Relieved by

Any movement

Flexion

Extension

Abduction

Adduction

Internal rotation

External rotation

Pronation

Supination

Circumduction

Painful surrounding structures including ligaments, bursae, muscles, bones, tendons

Skin overlying the joint

Peeling

Rash

scars

sinuses

Bruise

Muscle wasting

Feel

Crepitus

Instability

Joint locking

Deformity

Fixed

Reducible

Type

Flexion

Extension

Rotation

Abduction

Adduction

Dislocation

Posterior

Lateral

Medial

If e.g. anteromedial, choose both Anterior and Medial

Subluxation

Contracture

Flexion

Extension

Move

Weakness

Painful movement

Exacerbated by

Relieved by

Any movement

Flexion

Extension

Abduction

Adduction

Internal rotation

External rotation

Pronation

Supination

Circumduction

Stiffness

Morning stiffness

Inactivity stiffness

Restricted range of motion

Hypermobility

Other abnormal movement

Skeleton

Clavicle

Scapula

Acromion

Coracoid

Glenoid cavity

Humerus

Medial epicondyle

Lateral epicondyle

Coronoid process

Olecranon

Trochlea

Capitulum

Radius

Ulna

Radial collateral Ligaments

Ulnar collateral ligament

Carpal

Metacarpal

Proximal phalanx

Intermediate phalanx

Distal phalanx

Thumb

Index finger

Middle finger

Ring finger

Little finger

Findings

Resting pain

Painful movement

Tenderness

Swelling

Deformity

Consistency

Fragile

Stony hard

Soft

Thick

Weak

Ligaments findings

Laxity

tear

Strain(Partial tear)

Muscles

Deltoid

Pectoralis major

Trapezius

Biceps

Triceps

Teres major

Teres minor

Supraspinatus

Infraspinatus

Subscapularis

Subacromial bursa

Subtendinous bursa of subscapularis

Flexor digitorum superficialis

Flexor digitorum profundus

Flexor pollicis longus

Extensor pollicis longus

Flexor carpi radialis

Extensor digitorum

Sternomastoid

Shoulder

Arm

Forearm

Hand

Thenar

Hypothenar

interossei

Trapezius

Triceps

Hand

Inspection

Fasciculation

Contracture

Swelling

Spasm

Cramps

Twitching

Muscle bulk

Atrophy

Hypertrophy

Pseudohypertrophy

Wasting

Others

Pain

Tenderness

Stiffness

Weakness

Painful movement

Proximal muscle wasting

Distal muscle wasting

Lower limb Add New

Right

Left

Bilateral

Clubbing

Calcinosis

Distended veins

Varicose veins

Gouty tophi

Janeway lesion

Osler's nodes

Amputated

Peripheral cyanosis

Bowing of femur

Bowing of tibia

Xanthomata

Hypertrophic pulmonary osteoarthropathy

Pretibial myxedema

Limb length discrepancy

Limping

Appearance

Shortened

Externally rotated

Internally rotated

DVT Signs

Swelling

Redness

Calf tenderness

Pain

Distended veins

Vascular

Well perfused

Pain

Pulseless

Pallor

Paresthesia

Paralysis

Cold

Collapsed veins

Bleeding

Normal CRT < 2sec

CRT > 2sec

Shortened limb

Hair loss

Blanching skin

Dry gangrene

Wet gangrene

Gas gangrene

Buerger's test

Normal circulation

Abnormal circulation

Skin

Thick

Tight

Soft

Rough

Dry

Sweaty

Greasy

Clammy

Pigmented skin creases

Cyanotic mottled skin

Marble white skin

Temperature

Normal

Warm

Cold

Amputated

partial foot

Big toe

Index toe

Middle toe

Ring toe

Little toe

At the ankle (ankle disarticulation)

Below the knee (transtibial)

At the knee (knee disarticulation)

Above the knee (transfemoral)

At the hip (hip disarticulation)

Stump

Dry

Clean

Discharge

Infected

Inflammation signs

Ischemia

Bleeding

Phantom pain

Phantom limb sensation

Depression

Nails

Leukonychia

Koilonychia

Psoriasis

Nail pitting

Nail ridging

Nail dystrophy

Nail dysplasia

Brittle nails

Splinter hemorrhage

Onycholysis

Onychomycosis

Fungal infection

Paronychia

Beau's lines

brown nail band

Muehrcke's lines

Dilated nailfold capillaries

Nail overgrowth

Color changes

Blue

Red

Brown

White

Yellow

Green

Musculoskeletal

Hip

Greater trochanter tenderness

Lesser trochanter tenderness

Ischial tuberosity tenderness

Special tests

Leg length discrepancy

Right

Left

leg shorter on

Apparent

True

length measurement

Leg length discrepancy

Right

Left

leg shorter on block testing

Thomas’s test

Incomplete extension of the hip so fixed flexion deformity is apparent

Negative

Trendelenburg's sign

Hemipelvis tilts down due to its weak gluteal muscles

Negative

Thomson's(Simmond's) test

Failure of ankle plantarflexion when calf is squeezed

Knee

Baker’s cyst

Tenderness over

Tibial condyle

Femoral condyle

Tibial tuberosity

Patella

Patellar tendon

Quadriceps tendon

Deformity

Genu valgum(Knock knee)

Genu varum(Bow leg)

Knobby knee

Fixed flexion deformity

Patellar tap:

Tapping sensation or fluid impulse felt

Negative

Patellar apprehension test:

Patient actively resisting flexion of the extended knee

Negative

Bulge 'Ripple' test:

Bulge 'ripple' of fluid appeared on medial side of the knee

Negative

Extensor lag:

The knee cannot be fully extended while the patient is supine

Negative

Lachman's test:

Abnormal forward movement of the tibia while knee is 15-30 degrees flexed

Negative

Anterior drawer sign:

Abnormal forward movement of the tibia while knee is 90 degrees flexed

Negative

Posterior drawer sign:

Abnormal backward movement of the tibia while knee is 90 degrees flexed

Negative

Abnormal passive abduction:

Lateral(Valgus) force will cause medial space widening of tibia

Negative

Abnormal passive adduction:

Medial(Varus) force will cause lateral space widening of tibia

Negative

McMurray test(Medial meniscus):

Pain or click upon extending the flexed externally rotated abducted leg

Negative

McMurray test(Lateral meniscus):

Pain or click upon extending the flexed internally rotated adducted leg

Negative

Squat test:

Patient cannot squat with the feet flat on the ground so incomplete knee flexion

Negative

Foot & Ankle

Foot callosities

prominent metatarsal heads

Achilles tendon defect

Hallux rigidus

Plantar fasciitis

Achilles tendonitis

Tenderness over

Medial malleolus

Lateral malleolus

Proximal fibula

Patella

Patellar tendon

Achilles tendon

Deformity

Fixed plantarflexion deformity

Pes cavus(High arch)

Pes planus(Flat foot)

Hallux valgus(Bunion)

Hallux varus

Foot drop

Positional talipes

Splay foot

Talipes valgus

Talipes varus

Talipes calcaneus

Talipes equinus

Talipes equinovarus(Clubfoot)

Talipes calcaneovalgus

Talipes calcaneovarus

Hummer toes

Claw toes

Mallet toes

Special tests

Thomson's(Simmond's) test

Failure of ankle plantarflexion when calf is squeezed

Negative

Neuro

Tone

Increased

Decreased

Atonia

Spasticity

Flaccidity

Rigidity

Clonus

Power

Weakness

Add New

Hip

Flexion

Extension

Grade

Knee

Flexion

Extension

Grade

Ankle

Dorsiflexion

Plantarflexion

Inversion

Eversion

Grade

Toes

Dorsiflexion

Plantarflexion

Grade

Hoover's sign

While patient is supine and raising one leg upward, pressure of contralateral leg will be felt as It is extending down proving it has normal power

Negative

Reflexes

Knee(L3-L4)

Increased

Normal

Decreased

Present only with reinforcement

Slow relaxing reflex

Absent

Grade

Ankle(S1)

Increased

Normal

Decreased

Present only with reinforcement

Slow relaxing reflex

Absent

Grade

Plantar(S1-2)

Babinski sign(Extensor plantar response)

Negative

Cremasteric reflex(L1-2)

Positive

Negative

Sensation Add New

Pain

Absent

Reduced

Increased

Temperature

Normal

Impaired

Touch

Normal

Impaired

Vibration

Normal

Impaired

Joint position

Normal

Impaired

Two-Point Discrimination

Normal

Impaired

Stereognosis

Normal

Impaired

Graphesthesia

Normal

Impaired

Choose distribution of any finding

Glove and stocking distribution

Nerve distribution

Dermatomes distribution

Rash along dermatome

Site

Right face

Left face

Right trunk

Left trunk

Right upper limb

Left upper limb

Right lower limb

Left lower limb

Abnormal sensation

Paresthesia

Tingling

Sensory loss

Decreased sensation

Increased sensation

Allodynia

Hyperalgesia

Nerve injury

Superior gluteal nerve

Impaired hip abduction

Trendelenburg gait (Waddling gait)

Inferior gluteal nerve

Impaired hip extension

Difficulty raising from chair or climbing stairs

Femoral nerve

Impaired hip flexion

Impaired knee extension

Sensory loss on anterior thigh, medial leg and medial foot(Saphenous nerve)

Obturator nerve

Impaired thigh adduction

Sensory loss on medial thigh

Sciatic nerve

Impaired thigh extension

Impaired knee flexion

Loss of all functions below the knee

Sensory loss over posterior thigh

Sensory loss over leg except medial side

Sensory loss over foot

Tibial nerve

Impaired knee flexion

Impaired ankle plantarflexion

Impaired inversion

Sensory loss over leg except medial side

Sensory loss over sole of the foot

Deep fibular nerve

Impaired inversion

Impaired toes extension

Impaired ankle dorsiflexion (Foot drop)

Sensory loss over 1st web space between great and 2nd toes

Superficial fibular nerve

Impaired eversion

Sensory loss on anterolateral leg

Sensory loss on dorsum of foot except 1st web space

Joints

Hip

Knee

Ankle

Subtalar

Talocalcaneonavicular

Calcaneocuboid

Cuneonavicular

TMT

MTP

PIP

DIP

Big

toe

Index toe

Middle toe

Ring toe

Little toe

Inflammation signs

Redness

Warmth

Tenderness

Swelling

Consistency

Soft

Hard

Fluctuant

Impression

Bony

Soft tissue

Bursa

Effusion

Synovitis

Pain

Add New

Migratory

then to

At rest

Exacerbated by

Relieved by

Any movement

Flexion

Extension

Abduction

Adduction

Internal rotation

External rotation

Pronation

Supination

Circumduction

Painful surrounding structures including ligaments, bursae, muscles, bones, tendons

Skin overlying the joint

Peeling

Rash

scars

sinuses

Bruise

Muscle wasting

Feel

Crepitus

Instability

Joint locking

Deformity

Fixed

Reducible

Type

Flexion

Extension

Rotation

Abduction

Adduction

Dislocation

Posterior

Lateral

Medial

If e.g. anteromedial, choose both Anterior and Medial

Subluxation

Contracture

Flexion

Extension

Move

Weakness

Painful movement

Exacerbated by

Relieved by

Any movement

Flexion

Extension

Abduction

Adduction

Internal rotation

External rotation

Pronation

Supination

Circumduction

Stiffness

Morning stiffness

Inactivity stiffness

Restricted range of motion

Hypermobility

Other abnormal movement

Skeleton

ileum

Iliac crest

Pubis

ischium

Symphysis pubis

Femur

Medial femoral condyle

Lateral femoral condyle

Patella

Patellar ligament

Medial meniscus

Lateral meniscus

Anterior cruciate ligament

Posterior cruciate ligament

Tibial collateral ligament

Fibular collateral ligament

Tibia

Fibula

Medial tibial condyle

Lateral tibial condyle

Medial malleolus

Lateral malleolus

Calcaneal tendon

Talofibular ligament

Tarsals

Metatarsals

Proximal phalanx

Intermediate phalanx

Distal phalanx

Big toe

Index

Middle

Ring

Little toe

Findings

Resting pain

Painful movement

Tenderness

Swelling

Describe deformity

Consistency

Fragile

Stony hard

Soft

Thick

Weak

Ligaments findings

Laxity

tear

Strain(Partial tear)

Muscles

Vastus medialis

Sartorius

Gracilis

Semitendinosus

Semimembranosus

Biceps femoris

Gluteal

Hamstring

Quadriceps

Gastrocnemius

Hip

Thigh

Calf

Foot

Inspection

Fasciculation

Contracture

Swelling

Spasm

Cramps

Twitching

Muscle bulk

Atrophy

Hypertrophy

Pseudohypertrophy

Wasting

Others

Pain

Tenderness

Stiffness

Weakness

Painful movement

Proximal muscle wasting

Distal muscle wasting

Mental status

Appearance

General

Relaxed

Distressed

Needle marks/tracks suggesting drug abuse

Erosion of teeth enamel suggesting eating disorder

Superficial cuts on the body

Bruises suggestive of abuse

Superficial cuts on the body suggesting self-harm

Constricted pupils of drug abuse

Dilated pupils of drug abuse

Self-neglect

Self-injury

Mild tattoos

Marked tattoos

Body piercings

Apparent age

Looks older than stated age

Looks younger than stated age

Hygiene

Good

Poor

Smells of alcohol

Smells of urine or feces

Clothing

Normal

Too big

Too small

Torn

Dirty

Old

Pierced

Facial expression

Unchanging

Lack of expression

Startled

Power

Strong

Frail

Behavior

Psychomotor activity

Agitation

Retardation

Eye contact

Good

Poor

Activity

Hyperactive

Hypoactive

Cooperation

Cooperative

uncooperative

Abnormal movements

Tremors

Akathisia

Tardive dyskinesia

Akinesia

Bradykinesia

Hemiplegia

Quadriplegia

Paraplegia

Tics

Posturing

Stereotypy

Echopraxia

Chorea

Athetosis

Choreoathetosis

Dystonia

Motor behavior

Catatonic rigidity

Catatonic posturing

Catatonic excitement

Catatonic stupor

Waxy flexibility (Catalepsy)

Cataplexy

Anergia

Negativism

Automatism

Mannerism

Social behavior

Aggression

Disinhibition

Overactivity

Agitation

Compulsions

Underactivity

Motor retardation

Attitude

Seductive

Flattering

Charming

Eager to please

Entitled

Controlling

Hostile

Guarded

Critical

Antagonistic

Childish

Speech

Rate

Regular

Pressured

Slowed

Fluency

Staccato

Monotone speech

Broca’s(Motor) aphasia

Wernick’s(Sensory) aphasia

Volume

Normal

Low

Shouting

Whispering

Aphonia

Articulation

Stuttering

Slurred speech

Quantity

Poverty of speech

Poverty of speech content

Mutism

Selective mutism

Spontaneity

Spontaneous

Non-spontaneous speech

Mood

Problematic mood

Neutral

Depression

Elation

Euphoria

Euthymia

Anhedonia

Anxiety

Fear

Panic

Phobia

Anger

Suspicious

Irritable

Perplexity

Shame

Guilt

Grandiosity

Suicidal ideation

Range

Flattened (Nonreactive)

Expanded

Mood congruence

Congruent to circumstances

Incongruent to circumstances

Affect

Range

Flat (None)

Blunted (Shallow)

Restricted (Limited)

Full (Average)

Intense (More than normal)

Stability

Fixed

Labile

Appropriateness to thought content

Appropriate

Inappropriate

Thought process(Form)

Rate

Pressured

Slowed

Coherence

Coherent

Incoherent

Logic

Logical

illogical

Stream

Goal-directed

Circumstantiality

Tangentiality

Loosening of associations (derailment)

Flight of ideas

Word salad

Perseveration

Thinking

Concrete

Abstract

Other findings

Echolalia

Thought blocking

Clang association

Neologism

Verbigeration

Late response

Thought content

Content

Poverty of thoughts

Overabundance of thoughts

Obsession

Contamination

Orderliness

Sexual

Doubt

Worry

Guilt

Delusions

mood-congruent

mood-incongruent

Jealousy

Bizarre

Control

Grandiosity

Erotomania

Religious

Persecution (Paranoid)

Reference

Nihilistic

Somatic

Hypochondria

Guilt

Thought interference

infestation

self-accusation

Thought possession

Thought insertion

Thought withdrawal

Thought broadcasting

Suicidal ideation

Thoughts frequent

Thoughts infrequent

There is intent

No intent

There were attempts

No attempts

Active suicide

Passive suicide

Homicidal ideation

Thoughts frequent

Thoughts infrequent

There is intent

No intent

There were attempts

No attempts

Active suicide

Passive suicide

Other findings

Preoccupation

Rumination

Compulsions

Magical thinking

Ideas of reference

Overvalued ideas

Hypochondriasis

Perception

Hallucinations

mood-congruent

mood-incongruent

Visual

Auditory

Olfactory

Taste

Tactile/Somatic

Other findings

Pseudo-hallucinations

illusions

Depersonalization

Derealization

Cognition

Consciousness

Alert

Drowsy

Lethargic

Stupor

Coma

Confusion

Delirium

Dementia

Orientation

Oriented

Disoriented to time

Disoriented to place

Disoriented to person

Memory

Intact

Impaired immediate memory

Impaired recent memory

Impaired long-term memory

Anterograde amnesia

Retrograde amnesia

Hypermnesia

Confabulation

Anomia

Blackout

Fund of knowledge

Below average

Average

Above average

Keeping up with person’s education

Attention/concentration

Impaired

Distractibility

Inattention

Selective inattention

Hypervigilance

Calculation

Intact

Impaired

Abstract thinking

Impaired proverb interpretation

Impaired similarities test

Language

Impaired comprehension

Impaired reading

Impaired writing

Impaired repetition

Impaired naming

Communication

Intact

Impaired

Visuospatial ability

Intact

Impaired

Insight

No insight

Partial insight

Full insight

Judgement

Excellent

Good

Fair

Poor

Personality disorder

Paranoid

Schizoid

Schizotypal

Antisocial

Borderline

Histrionic

Narcissistic

Avoidant

Obsessive-compulsive

Dependent

Important Negative Findings

Generally

Conscious

Oriented

Normal speech

Mobilizing freely

Obeying commands

Moist mucus membranes

Normal skin turgor

CRT>2sec

HEENT

Patent nostrils without nasal discharge

Clear throat

Normal ear findings

Respiratory

BEAE without added sounds

CVS

S1 + S2 + 0

No increase in JVP

Abdomen

Soft and lax

Audible bowel sounds

No tenderness

No distention

No masses

No organomegaly

Neuro

No Focal neurological deficits

Normal coordination

Normal sensation

Normal tone

Normal power

Normal reflexes

Normal limb movements

Normal vision

Normal gait

Limbs

No edema

No hand and palmar changes

No nail changes

Normal pulses

Normal sensation

V/S

Normal rate

Regular rhythm

Normal volume

No respiratory distress

Afebrile

Submit