Recommended Physical Examination Concepts

This reference defines standard physical examination concepts and anatomical systems for documenting clinical examination findings.

Field	Translate	Details / What to Record
General Appearance	រូបរាងទូទៅ	Consciousness (alert/drowsy), Distress, Nutrition, Posture, Gait, Hygiene, Pallor, Jaundice, Cyanosis, Edema
ENT(ORL)	ការវាយតម្លៃប្រព័ន្ធប្រសាទឆ្លើយតប	Head, Eyes, Ears, Nose, Throat/Mouth
Cardiovascular System	ប្រព័ន្ធសរសៃឈាមបេះដូង	Inspection (chest), Palpation (apex beat), Auscultation (S1/S2, murmurs), Peripheral pulses
Respiratory System	ប្រព័ន្ធផ្លូវដង្ហើម	Chest symmetry, Expansion, Percussion (dullness), Breath sounds, Crepitations, Wheezing
Gastro-Intestinal System	ពោះ	Inspection (distension), Palpation (tenderness, organ size), Percussion, Bowel sounds
Central Nervouse System	ប្រព័ន្ធប្រសាទ	Mental status, Cranial nerves, Motor/sensory function, Reflexes, Coordination
Skin & Extremities	ស្បែក	Rashes, Lesions, Color changes, Ulcers, Turgor, Temperature
Glasgow Coma Scale	មាត្រដ្ឋានវាយតម្លៃកម្រិតស្មារតី	Structured consciousness assessment using Eye, Verbal and Motor responses, producing a GCS score from 3–15.
Urogenital System	ប្រព័ន្ធទឹកនោម និងប្រព័ន្ធបន្តពូជ	Genitourinary examination: urinary/genital findings, tenderness, swelling, discharge, lesions, etc.
Mental Status	ស្ថានភាពផ្លូវចិត្ត និងស្មារតី	Cognitive and behavioral assessment: appearance, behavior, mood, speech, orientation, memory, attention, thought process, etc.
Other body parts	ផ្នែកផ្សេងទៀតនៃរាងកាយ	Examination findings involving body parts or anatomical areas not covered by the standard examination sections above.