Doctor Speak for Presentations

Question 1

General Appearance (4)

Answer 1

1. Well-developed, well-nourished (WDWN)
2. Appears stated age
3. No apparent distress (NAD)
4. Alert and Oriented

Question 2

Vital Signs

Answer 2

1. BP
2. Pulse
3. Temperature
4. RR
5. BMI (kg/m2)

Question 3

HEENT

A. Skull

Answer 3

1. Normocephalic, Atraumatic (NC/AT)
2. No lesions or masses
3. Normal hair distribution (or Male pattern alopecia, thinning hair, etc)

Question 4

HEENT

B. Eyes

Answer 4

1. Pupils equal round and reactive to light and accomodation (PERRLA)
2. Extraocular muscles intact (EOMI)
3. Conjunctiva pink, no ocular discharge
4. Sclera white/clear

Question 5

HEENT

C. Ears

Answer 5

1. Pinna and tragus non-tender
2. External auditory canals clear (or wax occluded, etc)
3. Tympanic Membrane (TM) Pearly gray and translucent w/ normal light reflex, no effusion
4. Whisper test normal
5. Weber/Rinne w/in normal limits (WNL) or air conduction greater than bone conduction

Question 6

HEENT

D. Nares

Answer 6

1. Patent bilaterally
2. Septum Midline
3. Turbinates clear (or boggy, nasal discharge, etc)

Question 7

HEENT

E. Mouth

Answer 7

1. Good dentition
2. No lesions on buccal mucosa (cheeks), floor or roof of mouth
3. No erythema, Inflammation, or Exudate (E/E/I) on palate

Question 8

Neck

Answer 8

1. Neck supple
2. Trachea midline
3. Thyroid midline w/out goiter or nodules
4. No carotid bruits
5. Carotid pulsations 2+, equal, bilateral (2+/=/B)
6. No JVD
7. No anterior cervical, posterior auricular, supraclavicular, or epitrochlear lymphadenopathy (LAD)

Question 9

Lungs (pulmonary)

Answer 9

1. Anterior/Posterior chest wall w/out abnormalities (ie no barrel chest, pectus excavatum)
2. Normal Tactile fremitus
3. Lungs resonant to percussion
4. Clear to auscultation bilaterally (CTAB) or no wheezes, rales, or rhonchi (W/R/R)

Question 10

Back

Answer 10

1. Spine straight
2. No skin lesions
3. No costovertebral angle tenderness (CVAT)

Question 11

Cardiovascular

Answer 11

1. No tenderness to palpation
2. Normal S1/S2, regular rate and rhythm (RRR)
3. PMI non-displaced
4. No murmurs, rubs, or gallops (m/r/g)

Question 12

Abdomen

Answer 12

1. Scaphoid vs Protuberant
2. Normal active bowel sounds (NABS)
3. No renal bruit auscultated
4. No tenderness to light or deep palpation
5. No rebound tenderness or guarding
6. No spleen tip palpable
7. No hepatosplenomegaly (HSM)
8. Liver span right midclavicular line (X estimated cm)

Question 13

Extremities

Answer 13

1. No cyanosis, clubbing, or edema (c/c/e) (can mention shamroth’s sign)
2. Dorsalis pedis/posterior tibia; (DP/PT) pulses 2+/=/B
3. Can comment on hair distribution or skin, or any lesions ulcers, etc.