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H&P II Pulmonary Documentation (MED217) | Full Exam Template with Clinical Descriptions & Correct Findings | 2025/2026 OSCE Guide

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This document provides a structured, exam-ready pulmonary physical exam write-up aligned with MED217 – Pulmonary Clinical Skills and Documentation for the 2025/2026 academic year. Created for students preparing for OSCEs and clinical assessments, it features professionally phrased exam documentation across all standard components of the pulmonary physical exam—perfect for use in standardized patient scenarios or clinical notes. It includes: Patient positioning guidance (e.g., sitting upright) Thoracic inspection: chest wall movement, effort of breathing, shape, and symmetry Palpation: tactile fremitus, chest expansion, tenderness Percussion findings: symmetrical resonance, absence of dullness or hyperresonance Auscultation: clear bilateral breath sounds, absence of adventitious sounds (rales, wheezes, rhonchi), transmitted voice sounds Documentation of negatives (no cyanosis, clubbing, use of accessory muscles, or tracheal deviation) This resource is essential for: Medical students mastering physical exam documentation for OSCEs or clerkship write-ups Physician Assistant (PA) and Nurse Practitioner (NP) students learning structured charting of pulmonary findings Students preparing for clinical skills exams such as USMLE Step 2 CS, COMLEX PE, NCLEX, or university-based assessments International medical graduates (IMGs) learning U.S.-style physical exam phrasing With its precise, high-yield language, this document ensures you can confidently and accurately describe pulmonary findings during both mock and real clinical encounters. Keywords: pulmonary documentation, MED217, lung exam, breath sounds, tactile fremitus, rales, wheezes, rhonchi, auscultation, percussion, OSCE, clubbing, thoracic expansion, cyanosis, accessory muscles, tracheal deviation, clinical exam write-up, pulmonary physical exam

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acromegaly - 🧠 ANSWER ✔✔A disorder in adults in which the pituitary

gland produces too much growth hormone; appears in adulthood (while

gigantism appears in childhood)


alopecia - 🧠 ANSWER ✔✔an autoimmune disorder that hair loss in one or

more spots (usually on the scalp)


aphasia - 🧠 ANSWER ✔✔a neurological disorder caused by damage to the

portions of the brain that are responsible for language; patient has trouble

understanding language (written and verbal); usually due to stroke or head

injury


annulus - 🧠 ANSWER ✔✔a ring-like figure, part, structure, or marking

,aphthous ulcer - 🧠 ANSWER ✔✔AKA canker sore-typically recurrent round

or oval sores or ulcers inside the mouth on areas where the skin is not

tightly bound to the underlying bone, such as on the inside of the lips and

cheeks or underneath the tongue. They can also affect the genitalia in

males and females


ataxia - 🧠 ANSWER ✔✔loss of muscle control during voluntary movements;

usually due to damage to the cerebellum; can be due to a variety of

conditions (e.g. CVA, cerebral palsy, alcohol abuse)


athetoid movement - 🧠 ANSWER ✔✔slow, involuntary, convoluted, writhing

movements of the fingers, hands, toes, and feet and in some cases, arms,

legs, neck and tongue


ausculatory gap - 🧠 ANSWER ✔✔period of diminished or absent Korotkoff

sounds during the manual measurement of blood pressure.


auricle - 🧠 ANSWER ✔✔atrium of the heart; pinna of the ear; an angular or

ear-shaped lobe, process, or appendage


Bell's palsy - 🧠 ANSWER ✔✔idiopathic facial paralysis; sudden weakness

in the muscles on one half of the face


buccal - 🧠 ANSWER ✔✔of or relating to the mouth and or cheek

,cachexia - 🧠 ANSWER ✔✔weakness and wasting of the body due to

severe chronic illness


carotenemia - 🧠 ANSWER ✔✔clinical condition characterized by yellow

pigmentation of the skin (xanthoderma) and increased beta-carotene levels

in the blood


cerumen - 🧠 ANSWER ✔✔technical term for earwax


chloasma - 🧠 ANSWER ✔✔temporary condition, typically caused by

hormonal changes in which large brown patches form on the skin, mainly

on the face; affects pregnant women


choanae - 🧠 ANSWER ✔✔either of the pair of posterior apertures of the

nasal cavity that open into the nasopharynx—called also posterior naris.


creptation - 🧠 ANSWER ✔✔a crackling sound made in breathing by a

person with an inflamed lung, detected using a stethoscope.


cricoid cartilage - 🧠 ANSWER ✔✔ring shaped cartilage of the larynx; near

middle and center of neck


dizziness - 🧠 ANSWER ✔✔used to describe a range of sensations such as

feeling faint, woozy, weak, unsteady; "spinning"


COPYRIGHT©NINJANERD 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
3

, deviated septum - 🧠 ANSWER ✔✔thin wall (nasal septum) b/w your nostrils

is displaced to one side


defervescence - 🧠 ANSWER ✔✔the abatement of a fever as indicated by a

decrease in bodily temperature


decibel - 🧠 ANSWER ✔✔a unit to measure the intensity of a sound or the

power level of an electrical signal by comparing it with a given level on a

logarithmic scale


diurnal variation - 🧠 ANSWER ✔✔variation between a high temperature

and a low temperature that occurs during the same day


dysarthria - 🧠 ANSWER ✔✔difficult or unclear articulation of speech that is

otherwise linguistically normal; impaired movement of the muscles used for

speech production, including the lips, tongue, vocal folds, and/or diaphragm


dysphonia - 🧠 ANSWER ✔✔difficulty in speaking due to a physical disorder

of the mouth, tongue, throat, or vocal cords.


epistaxis - 🧠 ANSWER ✔✔nosebleed

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