Physical Examination Medical Transcription Words

PHYSICAL EXAMINATION:  Vital Signs:  The patient’s temperature is 97.8 degrees, pulse is 74, respirations 19 and blood pressure is 154/96.  General:  This is an obese female who is in no apparent distress.  Neurologic:  The patient is alert and oriented to person, place and time.  Her speech is fluent.  Language is intact.  Both short-term and long-term memory adequate.  Cranial Nerve Examination:  Pupils are equal and reactive at 3 mm and brisk.  Extraocular movements are intact.  Visual fields are intact.  Accommodation is intact.  Corneal reflex is intact.  Hearing is intact to finger rub.  There is no facial asymmetry.  Tongue is midline with good palate elevation.  Motor examination reveals the patient to have full strength, 5/5, in all four extremities.  There is no pronator drift, fasciculations or atrophy.  Deep tendon reflexes are physiologic and symmetric in all four extremities.  The patient’s fine motor coordination is intact with finger-to-nose and heel-to-shin testing performed bilaterally.  The patient’s Romberg is negative.  Tandem gait is steady.  Wide-based gait is steady.  The patient is walking around in the room with no apparent distress.  Sensory Examination:  There is no asymmetry of either body half or face to primary modalities.  Cardiovascular:  S1, S2, regular.  Respiratory:  Lungs are clear.

PHYSICAL EXAMINATION:  Afebrile, blood pressure 132/90, heart rate 74, and respirations 14. In general, an elderly Hispanic female in no acute distress. HEENT:  Normocephalic and atraumatic. Neck:  Supple. No jugular venous distention or carotid artery bruits. Lungs:  Clear. Respirations unlabored. Heart:  Regular rate and rhythm. S1 and S2. No extra heart sounds or murmurs. PMI nondisplaced. Abdomen:  Soft and nontender. Bowel sounds are present. Extremities:  Demonstrate no peripheral edema. Neurologic:  Alert, oriented, and grossly nonfocal.

PHYSICAL EXAMINATION:  Vital Signs:  Temperature is 98.4 degrees, pulse 78, respiratory rate 15 and blood pressure 132/82.  General:  He is a well-developed male, sedated, arouses, moves all four extremities, attempts to follow simple commands.  HEENT:  Male pattern alopecia.  Pupils are conjugate.  Oral endotracheal tube is in good position.  Neck:  Reveals no jugular venous distention, bruits, adenopathy, use of accessory muscles.  Lungs:  Lung fields reveal bibasilar crackles.  Heart:  No gallop or murmur.  Abdomen:  Distended, protuberant, hypoactive bowel sounds; otherwise, benign without organomegaly.  The umbilical incision is clean and dressed.  Genitourinary:  Foley catheter is in place.  Extremities:  Reveals no clubbing, cyanosis or edema.  Negative Homans sign.  No palpable cords.  Neurologic:  He is sedated, otherwise nonfocal.

PHYSICAL EXAMINATION:  On initial physical exam, temperature 97.8, respirations 16, blood pressure 102/58, pulse 82 and regular.  In general, the patient is a well-developed, well-nourished female, in no acute distress at the time of presentation.  HEENT exam is significant for pupils constricted and nonreactive.  Mucous membranes moist with no oral lesions.  Neck is supple with no thyromegaly.  Respiratory exam reveals bilaterally equal air entry with no wheezes or rhonchi.  Cardiovascular exam reveals PMI not palpable, regular rate and rhythm.  S1, S2, with no murmur.  Pedal pulses are present and there is no pedal edema.  GI exam reveals abdomen to be soft, nontender, nondistended with positive bowel sounds and no masses.  Musculoskeletal exam reveals strength 5/5 in bilateral upper and lower extremities.  Skin exam reveals no suspicious-looking lesions and no pressure ulcers.  Neurologic exam reveals cranial nerves II through XII to be grossly intact with intact sensation bilaterally.  Psychiatric exam reveals the patient to be alert and oriented x3 with appropriate mood and affect, slightly anxious.

PHYSICAL EXAMINATION ON ADMISSION:  General:  Well-developed, well-nourished, white female in mild distress.  HEENT:  Head is normocephalic.  She does have an abrasion on her left forehead and there is a left anterior/superior skull abrasion.  Pupils equal, round, and reactive to light.  Extraocular movements intact.  No pain at TMJ.  Neck:  Cervical C-collar in place.  No pain on palpation.  Cardiovascular:  Regular rate and rhythm.  Clear S1, S2.  Respiratory:  Lungs clear to auscultation bilaterally.  Abdomen:  Soft, nontender, nondistended, positive bowel sounds.  Musculoskeletal:  Right lower extremity:  The patient resting with right hip flexed but not significantly rotated.  No active range of motion of the right hip secondary to pain.  Pain with all passive range of motion of the right hip as well.  Mild tenderness to palpation at the right lateral knee.  Right knee active range of motion limited by hip pain.  The patient tolerates passive range of motion of the right knee well.  Mild AP instability noted at the right knee while the patient was under conscious sedation for reduction of her right hip, which was posteriorly dislocated at the time of admission but well reduced under conscious sedation.  Bilateral upper extremities and left lower extremity reveal no deformity, no tenderness to palpation.  Full pain-free active range of motion in all joints with 5/5 strength in all major muscle groups and sensation intact to light touch throughout with no gross instability and brisk distal capillary refill.  It should also be noted that the patient never displayed any neuro deficits in her right lower extremity with sensation intact to light touch throughout the right lower extremity and 5/5 strength in her tibialis anterior, extensor hallucis longus and gastroc-soleus musculature.

PHYSICAL EXAMINATION:  Vital Signs:  Temperature 100.2, respiratory rate 28, blood pressure 122/88, pulse rate 96, and 98% oxygen saturation on 2 liters nasal cannula.  General Appearance:  No acute distress.  Eyes:  PERRLA.  EOMI.  ENT:  Normal nasal mucosa.  Oral mucosa is moist without evidence of exudates or lesions.  Neck:  No adenopathy or masses were appreciated.  Thyroid was normal.  Respiratory:  Increased respiratory effort was appreciated.  Decreased air entry bilaterally.  Crackles at the left base.  Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.  No S3, S4, murmurs, rubs or clicks were appreciated.  No JVD, no pedal edema, 2+ pedal pulses.  Abdomen:  Soft, nontender, nondistended, positive bowel sounds throughout.  No organomegaly.  No abdominal bruits were appreciated.  GU:  Normal testes and penis.  Lymphatics:  No neck or axillary adenopathy was appreciated.  Musculoskeletal:  The patient did have 4/5 strength in the upper and lower extremities bilaterally.  The patient appeared to have normal muscle tone throughout.  Skin:  The patient had no rashes or lesions.  However, did have dry, scaly skin on the lower extremities bilaterally.  Neurologic:  Cranial nerves II through XII are grossly intact bilaterally.  DTRs were normal at the level of the patellar and Achilles tendons.  No focal motor or sensory deficits were appreciated.  Psychiatric:  Normal judgment and insight.  The patient was alert and oriented x3.  Recent and remote memory intact.  Mood and affect were normal.

PHYSICAL EXAMINATION:  His blood pressure is 120/74. He is afebrile with stable vital signs. He is a middle-aged Hispanic gentleman, who appears comfortable sitting in a chair. Alert and oriented to person, place and time. His head and neck exam is unremarkable. The patient wears corrective glasses. Funduscopic exam reveals somewhat tortuous arteries without any evidence of hemorrhage or papilledema. His ear exam is unremarkable. Tympanic membranes are gray with good cone of light bilaterally. Ear tunnels are patent. Nasal passages are patent. No evidence of erythema. Oral cavity is without evidence of exudate in pharynx. No swallowing problem is observed. He has a long uvula. No orthodontic work. He has significant caries with fillings. No evidence of infection in the mouth. Gag reflex is positive. No evidence of lymphadenopathy in neck. No JVD. Chest of normal configuration with some muscle wasting. He does not appear cachectic, but is skinny. His lungs are clear to auscultation bilaterally. Heart reveals a regular rate and rhythm. S1 and S2 present. No murmurs, rubs or gallops identified. Abdomen:  Slightly distended, not obese, with positive bowel sounds and negative Murphy sign. Abdomen is nontender to palpation throughout. Neurologic:  Reveals muscle strength 3/5 in left lower extremity, mostly in the proximal thigh. No footdrop. The rest of neurological exam is unremarkable. Cranial nerves II through XII grossly intact. Skin without rashes or cyanosis.

PHYSICAL EXAMINATION:  Today, visual acuity is 20/40 in both eyes. Intraocular pressures are 18 in both eyes. Slit-lamp examination is remarkable for a very mild cataract in both eyes. Dilated funduscopic examination in the right eye reveals mild drusen in the posterior pole. In the far superior nasal periphery, there is a flat, pigmented lesion. This lesion could be either a choroidal nevus or congenital hypertrophy of the retinal pigment epithelium. Dilated funduscopic examination in the left eye revealed a small, flat, choroidal nevus just superior to the fovea and drusen within the posterior pole.

PHYSICAL EXAMINATION:  On physical exam, the patient has an exquisite pain with internal rotation of the right hip to about 5 degrees of internal rotation. Her external rotation is about 20 degrees and she has pronounced pain, greater than with anterior impingement.  She has a positive posterior impingement sign.  Her left hip, she has about 5 degrees of internal rotation and 25 to 30 degrees of external rotation, but this is not painful.  She has 5/5 iliopsoas, quad, and hamstring strength.  She has 5/5 EHL, AT, gastrocnemius-soleus and peroneal strength bilaterally. She has 2+ pulses.  Bilaterally sensation is intact to light touch of both lower extremities.  On her right side, she has about 15 cm distance between the table and her knee during a fabere test, which is positive as well and this is significantly different than the left side, which she can get down to about 5 inches; this is also known as Patrick’s test.  She has no pain with log roll with either side, and when she lies flat with her leg externally rotated, she does note an ache in the posterior part of her buttocks, which may or may not correlate with posterior impingement sign.

PHYSICAL EXAMINATION:  On physical examination, he has no tenderness on the medial collateral. No tenderness on the lateral compartment of the left knee. Minimal effusion is noted.  He does have full extension and he can flex to over 100 degrees, left knee flexion.  He has a negative Lachman test.  He has no excursion with varus-valgus stress and no pain.  He has no pain or sign of chondromalacia with compression of the patella in the patellofemoral joint.  No laxity of his patella. Anterior drawer test is negative.  Positive endpoint.

PHYSICAL EXAMINATION:  Blood pressure 136/72 and pulse 72. In general, this is a pleasant female in no acute distress. Alert and oriented x3. HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. No cervical lymphadenopathy is noted. No mucosal lesions. Neck: No cervical lymphadenopathy. Neck is supple. Cardiovascular: S1, S2, regular rate and rhythm. No murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. No wheezes or crackles. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities: There is some evidence of mild lower extremity edema with the left greater than the right. The extremities are warm to touch with positive palpable DP pulses. There is some evidence of actinic skin damage diffusely on her extremities. Skin: Over the medial aspect of her calves bilaterally, there is a petechial, violaceous, nonraised, nonblanching rash that is visible on both calves bilaterally. There are small, dark red 1 to 2 mm violaceous lesions, which are nonpalpable. This area extends approximately 5 to 6 inches x 2 inches on either leg. Area is warm to touch. There is no pain to palpation over the calves bilaterally. There is also no evidence of trauma over the lower extremities.

PHYSICAL EXAMINATION:  Today shows that his blood pressure is 126/80, pulse is 66 and regular, respiratory rate is 14. Heart is normal. There is no evidence of ocular or cervical bruits. There is no evidence of temporal tenderness. His concentration seems to be somewhat diminished, but otherwise, his language structure is normal, naming is normal, multi-step commands that require conceptualization were done fairly well, although with some delay and with repeated attempts. His pupils were equal and reactive to light. The fundi showed sharp disk margins, no retinal emboli. The visual fields were full. Extraocular eye movements were intact; although, he seems to have diminished pursuit over to the left side and gaze nystagmus to the left more than the right and at one point seemed to close the right eye and perhaps has mild skew deviation, but he denied any diplopia. Upgaze seemed within normal for age. Convergence is normal. There is mild dysarthria, which is corroborated by the family. His lingual movements are somewhat slowed and inarticulate. There is some asymmetry with flattening of the right nasolabial fold. The tongue is normal. Motor examination as to the tone, bulk, strength is normal; seems to have slightly decreased fine motor movements in the right hand than the left, but feels that the hand is unchanged from his baseline. Deep tendon reflexes are 1+ at the knees and at the ankles, +1 in the upper extremities. The toes are downgoing. There may be some vibratory loss. He walks with a slightly wide base, but is steady. There is no limb dysmetria or gait ataxia. There is some decreased arm swing on the right side as compared to the left.

PHYSICAL EXAMINATION:  Height 5 feet 4 inches, weight 132 pounds, blood pressure 110/72, pain score 0. Her abdomen is soft, nontender. No masses. No ascites. Pelvic:  Vulva:  No lesions seen. There is a 3 cm mobile Bartholin’s gland cyst on the left, which is deep and nontender. Vagina:  No discharge. Cervix:  Nulliparous. Uterus is retroverted, slightly irregular, but normal size. Adnexa:  Nontender and nonpalpable. A Pap smear was obtained.

PHYSICAL EXAMINATION:  Well-developed, well-nourished male in no acute distress. Blood pressure in the left arm with a large adult cuff is 166/106. Blood pressure in the right arm with a large adult cuff is 160/104. Cardiac:  S1, S2, regular rate and rhythm. No murmurs, rubs or gallops. Lungs:  Clear to auscultation bilaterally. Neck is supple without lymphadenopathy or thyromegaly. Bilateral TMs are dull and slightly erythematous. Oropharynx:  Pink with erythematous cobblestoning. No tonsillar enlargement or exudate.

PHYSICAL EXAMINATION:  Height 4 feet 10 inches, weight 166 pounds, blood pressure 136/86, pain score 0. External Genitalia:  Atrophic. The vagina reveals no discharge. Microscopic exam negative for hyphae, negative for clue cells, negative for whiff, negative Trichomonas. No signs of red blood cells. Cervix is clean, closed, nontender. Uterus and adnexa reveal no masses.

OBJECTIVE:  On examination of the right upper extremity, the skin is circumferentially intact. There is deformity of the right wrist. There is resolving ecchymosis. The hand is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the radial, ulnar, and median nerves. She is able to actively flex and extend the fingers and thumb at the MP and IP joints. She is able to flex and extend the wrist without any pain. There is minimal tenderness to palpation over the distal radius. There is no tenderness to palpation of the distal ulna. On examination of the right hip, the surgical skin incisions are healed with no local signs of infection. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the sural, saphenous, superficial peroneal, deep peroneal, and tibial nerves. She is able to actively dorsiflex and plantarflex the foot and toes against gravity. There is no calf pain, swelling or tenderness to palpation. There is no pain with gentle passive range of motion of the right hip. She is able to extend the knee from a flexed position.

PHYSICAL EXAMINATION: Blood pressure 124/78, pulse 72, and respiratory rate 18. Weight 142 pounds. Head: Normocephalic and atraumatic. Sclerae were white and pupils equal and briskly reactive. Disk margins were sharp bilaterally. Nose and throat were unremarkable. Carotids without bruit and heart sounds are regular. She had good distal pulses. On neurological examination, she had normal mental status. She was alert, attentive, and oriented. She had normal speech without sign of dysarthria or aphasia. On cranial nerve testing, visual acuity corrected with eyeglasses was 20/30-1, both eyes, on the Jaeger card. She had full visual fields and ocular motility. She had very slight torsional nystagmus in a counterclockwise direction with gaze to the right. She had normal facial sensation and strength. Hearing was symmetric bilaterally. Palate elevated well. Sternocleidomastoid and trapezius strength were full and tongue protruded midline. On motor exam, she had no pronator drift. She had full strength throughout. She was tremulous on finger-to-nose bilaterally. She had no rest tremor. She had good amplitude and rhythmicity of rapid alternating movements. She had stable stance and gait both with and without use of cane. She could take steps on heels and on toes. Tandem was fairly steady. Sensory exam was significant for decreased pinprick in both lower extremities. Vibration was present at feet and extinguished slightly early. Position was intact. Reflexes were normoactive and toes were downgoing.

OBJECTIVE:  Weight 172, height 5 feet 4 inches, blood pressure 126/78, pulse 88 and regular. Neck:  Supple. No increased adenopathy. Thyroid not enlarged. Chest:  Clear to P and A. No rales, rhonchi or wheezes. Heart:  Normal sinus rhythm without murmurs. Breasts:  Without masses or tenderness. Abdomen:  Soft and nontender. LKKS nonpalpable. Bowel sounds good. Pelvic:  BUS clear. Vagina clean. Cervix clean. Uterus:  Small, freely movable and nontender. Adnexa clear. Extremities:  Full range of motion. Pulses 2+ bilaterally. DTRs 2+ bilaterally.

PHYSICAL EXAMINATION:  Height 5 feet 6 inches.  Weight 122 pounds. Stands with level pelvis, is decompensated, perhaps 10 cm anterior and perhaps another 10 cm to the right. She has a significant kyphoscoliosis. However, she has no trigger point tenderness or point tenderness over any of the spinous processes. She is minimally correctable. Her gait is reciprocal. Her strength exam shows no isolated deficits. Her reflexes at the knees and ankles were quite benign. Sharp, dull sensation is intact. She did not exhibit any root tension signs.