Suggested Phrases for Doctors
Title | Verbal Trigger | Content |
Normal abdomen | Normal abdominal examination | Abdomen: Soft and non-tender, normal bowel sounds in all four quadrants, no palpable masses. No hepatosplenomegaly. No costovertebral angle tenderness. |
Neurological examination | Normal neurological examination | Neurological examination: Awake, alert, and oriented. Pupils equal and reactive to light. Normal facial motor function. Symmetric strength and sensation in all extremities. No focal neurological deficits. Normal pace and coordination. Finger-nose test normal. Heel-knee test normal. Negative Romberg test. Downward plantar reflexes. |
Auscultation of the lungs | Normal lung sounds | Normal respiratory rate. No wheezing or crackles. Vesicular breath sounds bilaterally at the lung bases. |
Cor (Heart) | Normal heart sounds | Heart: Regular rhythm matching the peripheral pulse. Clear tones, no murmurs. No stenosis murmur over the aortic area. |
Suggested Phrases for Physical Examinations
Title | Verbal Trigger | Content |
Shoulder ultrasound | Shoulder ultrasound | Ultrasound examination of the right/left shoulder shows an intact long head of the biceps located in the intertubercular sulcus. No signs of synovitis or dislocation upon dynamic examination. Subscapularis was intact with no signs of tendinopathy. Supraspinatus was intact with no signs of rupture or tendinopathy. Infraspinatus was unremarkable. No impingement signs under the acromion during dynamic testing. The subdeltoid-acromial bursa was normal. The posterior part of the labrum was unremarkable. The acromioclavicular joint shows no signs of osteoarthritis or arthritis. |
Normal knee examination | Knee examination | Inspection: Functional tests - Squatting - Single-leg squat - Hopping/jumping - Walking
AROM - Flexion: - Extension:
PROM - Flexion: - Extension:
Isometric tests - Flexion: - Extension:
Special tests - Lachman’s test - Posterior drawer test - Pivot shift test - MCL/LCL test - McMurray’s test - Appley’s test - Patella dip test |
Special hip tests | Hip examination | FADIR test: |