e.g., well-appearing, in no acute distress, alert, appropriate, well nourished, cooperative, non-combative, normal level of consciousness, good hygiene, conversational, Pleasant, comfortable Thin/ cachectic, disheveled, nonverbal Confused, anxious

e.g., no gross deformities, PERRL, normal conjunctivae, mucous membranes moist, no scleral icterus, Alopecia, Sinus tenderness, clear nasal discharge, adenopathy, no sinus tenderness, lumps, thin hair, sclera icteric, etc

e.g., supple, no lymphadenopathy, no lumps, no thyromegaly, no nodules, midline trachea, goiter, tracheostomy, tracheal deviation, lymphadenopathy, cervical spine tenderness, abnormal curvature of the cervical spine

e.g., normal heart sounds, regular (irregular) rate and rhythm, murmur, no JVD, no chest wall tenderness, no scars, no orthopnea, sternal tenderness, chest wall tenderness, JVD present, sternotomy scar, pacemaker

e.g., normal effort, no audible wheezing, no rhonchi, no chest wall tenderness, chest wall symmetrical on inspiration, good inspirational effort, increased work of breathing, audible wheezing, audible rhonchi/gurgling, chest wall tenderness, surgical scars

e.g., soft, non-tender abdomen, non-distended, no masses, no hernias noted, no hepatomegaly, no splenomegaly, firm, tender, distended, colostomy, ileostomy, umbilical hernia, ventral hernia, hepatomegaly, splenomegaly

e.g., voiding without difficulty and pain, clear to light yellow urine, no CVA (costovertebral angle) tenderness, bladder non distended, bladder non tender, incontinence, dysuria, hematuria, urinary retention, cloudy, indwelling catheter, bladder distended, inguinal hernia, urostomy, masses

e.g., normal muscle tone, normal muscle bulk, no gross deformities, normal ROM, normal spinal alignment, no spinal tenderness, no extremity tenderness, decreased muscle tone, decreased muscle mass, limited ROM, contractures, joint swelling, joint tenderness, stiffness, scoliosis, kyphosis, muscle weakness, normal (abnormal) tone, obvious deformities, misalignment

e.g., alert and oriented (x1, 2, or 3), cranial nerves grossly intact, sensory grossly intact, motor skills grossly intact, cranial nerve disfunction, disoriented, decreased sensation, decreased motor ability, paraplegia, quadriplegia

e.g., no edema present, no tenderness, no stiffness, no joint swelling, no tremors, normal alignment, varicose veins, stiffness, tenderness, mild edema, significant edema, amputation, cast in place, Charcot foot

e.g., normal, no rash, no cysts, no dry skin, no nevi, rash, cyst, dry skin, moist, maceration, nevus, hyperpigmentation, tattoos, hemosiderin staining, jaundice

e.g., appropriate, normal mood, calm, normal affect, flat affect, combative, confused, depressed, sad, visual, auditory or olfactory hallucinations, anxious