Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Medical Transcription Physical Examination Words Phrases

PHYSICAL EXAMINATION: The patient is wasted, extremely poor nutritional condition. His temperature max last night was up to 104.1. His blood pressure was at 104/66, respiratory rate of 19, and heart rate of 92. His HEENT exam shows only jaundice. No other ocular alterations. Good ocular movements. The nose is normal. The mouth and oral mucosa show no lesions. The throat shows no abnormalities. The neck is supple. No neck vein distention. No supraclavicular adenopathy. No lateral cervical adenopathy. The neck veins are flat. The carotid pulses are normal. The thyroid is in the normal range. The chest is symmetric. There are decreased breath sounds in the right base with no wheezes or rhonchi. No signs of consolidation. The heart sounds are regular, rhythmic, with no murmurs, gallops, or rubs. The abdomen is soft. There is a small incision in the midline, above the umbilicus, in the epigastric area from the Roux-en-Y derivation and is well healed with no fluctuation, induration, redness, or cellulitis. The abdomen is tender in the right upper quadrant with some firmness in this area. There are no other masses palpable. The spleen is not palpable. The bowel sounds are normal. The CVA angles are not tender. The inguinal area shows no adenopathy. External genitalia normal. There is no CVA angle tenderness. The extremities show muscle wasting. No arthritis or phlebitis. Good peripheral pulses. No other lesions. The skin shows no abnormalities. Neurological examination shows no focal findings.

PHYSICAL EXAMINATION: Temperature 97.4, pulse 57, blood pressure 87/51, and respiratory rate 17 to 19 and nonlabored. In general, the patient is awake and alert. At this time, she is not acutely toxic. HEENT: Head atraumatic and normocephalic. Pupils round and reactive bilaterally. Sclerae anicteric. Conjunctivae not injected. The patient does have some very mild periorbital edema evident but no cellulitis evident. Oral mucosa moist. No thrush. No pharyngitis. No oral ulceration. Neck: Supple. No meningismus at this time. Trachea midline. No palpable thyromegaly. Lymph: No significant cervical or supraclavicular adenopathy. Chest: Symmetrical excursion. Lungs are clear to auscultation without wheezes. Heart: Regular rate and rhythm without rub. No frank regurgitant murmur. Abdomen: Normoactive bowel sounds. No guarding. No rebound tenderness. No palpable hepatomegaly. Abdomen was globular. Back: No CVA tenderness. No point tenderness. Extremities: No clubbing or cyanosis. No palpable cords. No calf tenderness to palpitation. Skin is without diffuse rash. No vesicles. No bullae. No Janeway lesions or Osler nodes. The patient had grossly intact strength in upper and lower extremities. She does have a tremor consistent with her Parkinson’s diagnosis.

PHYSICAL EXAMINATION:  General:  Middle-aged female, lying in bed, not in any acute apparent distress at this time.  Alert, awake, and oriented x3.  Vital Signs:  Blood pressure 133/66, pulse 82, and respirations 21.  The patient is afebrile.  T-max 100 yesterday.  HEENT:  Extraocular muscles are intact.  Pupils are round and reactive.  No icterus.  The patient has mild pallor.  No oral lesions.  No throat congestion.  Ears clear.  Neck:  Supple.  No jugular venous distention.  Lungs:  Good bilateral air entry.  Clear to auscultation.  No crackles or rhonchi are appreciated.  Heart:  S1, S2 audible.  Regular rhythm.  No audible murmur.  Abdomen:  Soft, bulky, nontender, positive bowel sounds.  Extremities:  The patient has a linear incision in the right lower extremity.  Dressing is in place.  Hemovac is in place.  Her right foot is slightly swollen but warm to touch.  She has bounding dorsalis pedis, very well palpable, with strong posterior tibial pulse.  Her left foot is also warm to touch and has weak but palpable dorsalis pedis and posterior tibial pulses.  No evidence of ulcers.  Neurologic:  She is grossly nonfocal.

PHYSICAL EXAMINATION:  This is a (XX)-year-old gentleman who is alert and oriented and does not appear to be in any distress.  Vital Signs:  Blood pressure 124/75, heart rate of 78, respirations are 21, temperature normal limits, and saturations are 97% on 2 liters via nasal cannula.  HEENT:  Pupils are round and reactive to light equally.  Oral mucosa is pink and moist.  No lesions noted.  Neck is supple.  There is jugular vein distention noted bilaterally.  Lungs: Inspiratory crackles bilaterally.  Abdomen is soft and slightly distended with positive bowel sounds.  Lower extremity show trace of lower extremity edema, from the knee down, on the left.  On the right, slightly erythematous skin over the ankle area and just poking through the bandages I can see reddened skin with what appears to be healing wound on the right.  I do not see any drainage; however, it is mildly malodorous.  Neurologically, no focal deficits noted.

PHYSICAL EXAMINATION:  General:  Awake and oriented to time, place, and person.  Appears comfortable at this time, not in respiratory distress.  Vital Signs:  Blood pressure is 112/52, heart rate of 85, respiratory rate of 21, temperature 99.8 degrees on room air, and saturation 97% on 2 liters nasal cannula.  HEENT:  She has pink conjunctivae and anicteric sclerae.  Morbidly obese.  Thyroid is not enlarged.  Neck:  Supple.  She has some contusion and hematoma in the left facial area.  Lungs:  She has bilateral air entry with clear breath sounds.  Heart:  She has good S1 and good S2.  No murmurs appreciated.  Abdomen:  Soft, flabby, and nontender without hepatosplenomegaly.  Extremities:  Shows grade 1 bipedal pitting edema.  There are surgical staples noted on the right knee.

PHYSICAL EXAMINATION:  Today shows a blood pressure of 138/82. Pulse is regular. Respiratory rate is normal. No bruits. Extraocular eye movements show decreased abduction of the left eye, horizontal diplopia with horizontal separation of the images on left lateral gaze. Cover-uncover test indicates that the culprit is the left abducens nerve. There is no ptosis. Pupils are equal and reactive. Face is symmetrical. Tongue and palate are normal. Facial sensation is normal. Dried herpetic lesions along the upper cervical level of C2-C3 and no herpetic rash across the scalp, but tenderness and swelling in the occipital area along the occipital nerve on that side. Decreased range of motion of the neck because of this discomfort. No evidence of motor weakness or drift. Fine and coarse motor movements are normal. Deep tendon reflexes are +2 in the upper extremities and at the knees; +1, left ankle; absent, right ankle. Toes are downgoing, dysesthesia. No dysmetria. With one eye closed, she has no gait ataxia and her balance is relatively good.

PHYSICAL EXAMINATION:  Vital signs have been reviewed.  Head:  Normocephalic with normal hair distribution.  No evidence of trauma.  Ears:  No purulent discharge.  Eyes:  Conjunctivae pink with no scleral jaundice.  Nose:  Normal mucosa and septum.  Mouth:  Normal gums and tongue.  Throat:  Somewhat crowded oropharyngeal tissues.  Neck:  Supple with no cervical or supraclavicular lymphadenopathy.  Trachea is midline.  Thyroid is not palpable.  Respiratory:  Normal symmetrical expansion of both hemithoraces.  Coarse breath sounds with scattered rhonchi and wheezing.  Cardiovascular:  S1, S2 normal.  No murmurs or gallops.  Abdomen:  Soft and nontender.  No organomegaly.  Musculoskeletal:  No swelling or effusion in any of the joints of the hand or feet.  No peripheral edema.  He does have pitting edema in both lower extremities.  Skin:  Normal color, turgor and temperature.  No ulcerations or rashes noted.  Lymphatics:  No cervical, supraclavicular or epitrochlear lymphadenopathy.  Neurologic:  Limited exam, as he is awake, alert and appropriate with no obvious focal deficit.

PHYSICAL EXAMINATION:  Vital Signs:  At the time of admission, his vital signs were temperature 97.4 degrees, pulse 120, monitor shows atrial fibrillation, respiration 19, blood pressure 168/84.  HEENT:  Pupils were equal and reactive.  Extraocular movements were intact.  Neck:  No raised JVP.  Carotid pulses were +2.  No bruits.  No thyromegaly.  No enlarged lymph nodes.  Chest:  Clear.  No chest wall tenderness.  Lungs:  Clear.  Heart:  Heart sound S1 is variable.  The patient with atrial fibrillation.  S2 is normal.  No S3 or S4.  There is 2/6 systolic ejection murmur at the base.  Abdomen:  Soft.  Bowel sounds were positive.  Extremities:  There is no edema or deformity.

PHYSICAL EXAMINATION:  General:  This is a (XX)-year-old markedly anxious female.  She answers questions appropriately.  Vital Signs:  Blood pressure is 133/67, pulse 69, respirations 19, saturation 98% on room air.  The patient is afebrile.  HEENT:  Head is normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Conjuctivae are clear.  Pulmonary:  Breath sounds are clear bilaterally.  Cardiac:  Heart has regular rate and rhythm.  Normal S1, S2.  There are no appreciable murmurs, rubs or gallops.  Abdomen:  Obese.  Soft, nontender, and nondistended.  Audible bowel sounds.  No palpable masses.  Extremities:  Warm without edema.  Peripheral vascular, carotid, and posterior tibials were 2/4 bilaterally.

PHYSICAL EXAMINATION:  The patient is a (XX)-year-old woman who is alert and oriented x3, comfortable at rest. Vital Signs:  Temperature of 97.6 degrees, heart rate of 74, blood pressure 112/72, and respirations of 15.  Head and Neck:  Shows pupils equal, round, reacting to light and accommodation.  Extraocular muscles are intact.  ENT examination normal.  There is no JVD.  There is no lymphadenopathy.  No thyromegaly.  Neck:  Supple.  Chest:  Shows first and second heart sounds normally heard.  No third sound, no fourth sound, and no murmurs.  Lungs:  Auscultation of the lungs show bilateral vesicular breath sounds.  Abdomen:  Examination of the abdomen shows a soft and scaphoid abdomen.  There is a deep tenderness in the right upper quadrant of the abdomen.  The liver span is 11 cm.  It is tender.  There is no splenomegaly.  No ascites.  Normal peristaltic sounds are heard.  Extremities:  No edema, no rash.  Neurologic:  No focal neurological deficit.

PHYSICAL EXAMINATION:  General:  The patient is alert, awake, oriented, in no respiratory distress.  Vital Signs:  Blood pressure is 103/72, pulse is 103, respirations 22, and pulse oximetry 97% on room air.  The patient is afebrile.  HEENT:  Sclerae nonicteric.  Conjunctivae pink.  No tenderness in the maxillary or frontal sinus area.  Neck:  No mass.  No lymphadenopathy.  Chest:  Bilateral expiratory wheezing.  Air exchange is fair.  Heart:  S1 and S2.  Regular rate and rhythm.  Abdomen:  Soft, nondistended, and nontender.  Minimal epigastric discomfort noted but no sign of acute abdomen.  Extremities:  No edema, no clubbing, no cyanosis.

PHYSICAL EXAMINATION:  Vital Signs:  Temperature 99.6.  Maximum temperature 101.  On admission, respiratory rate 18, blood pressure 124/56, pulse 96.  General Appearance:  In no acute distress.  Eyes:  Positive scleral icterus was appreciated.  PERRLA.  EOMI.  Funduscopic exam was within normal limits.  Ear, Nose, and Throat:  The patient did appear to have dried blood in the left nasal passage as well as some soft palate petechiae.  Oral mucosa was moist without evidence of exudates or ulcers.  Neck:  No masses or adenopathy was appreciated.  Thyroid was normal.  Respiratory:  Lungs were clear to auscultation bilaterally.  No wheezes, rhonchi or rales were appreciated.  The patient did have normal respiratory effort and no pleuritic chest pain.  Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.  No S3, S4, murmurs, rubs or clicks were appreciated.  No JVD.  No abdominal bruits.  No pedal edema, 2+ pedal pulses bilaterally.  The patient did have pectus excavatum and a petechial rash over the anterior chest.  Abdomen:  Soft, nontender to palpation, nondistended.  The patient did have hepatosplenomegaly.  No additional masses.  No abdominal bruits.  Genitourinary:  Exam was deferred.  Lymphatics:  No neck or axillary adenopathy.  Musculoskeletal:  The patient did have 5/5 strength throughout all extremities, normal muscle tone.  No cyanosis or clubbing of the extremities.  Skin:  The patient did have a petechial rash on the anterior chest as previously indicated.  In addition, he did have ecchymotic areas on the ulnar aspect of the distal forearm as well as left shin.  Neurologic:  Cranial nerves II through XII were grossly intact bilaterally.  DTRs were normal at the level of patellar and Achilles tendon.  Negative Babinski.  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:  Vital Signs:  Stable.  The patient is afebrile.  General:  Alert and oriented x3.  Good historian, cooperative throughout the examination.  HEENT:  Pupils are equally round and reactive to light.  Extraocular muscles are intact.  Throat is clear.  Neck is supple.  No masses.  No scleral icterus.  Mucous membranes are moist.  Heart:  Regular rate and rhythm.  Lungs:  Scattered crackles bilaterally.  Abdomen:  Soft.  There seems to be some mild tenderness in the right upper quadrant.  There is no Murphy, McBurney or Lloyd sign.  There is no rebound or guarding.  There is mild distention to the abdomen.  Extremities:  No edema, good range of motion.  Neurological:  Cranial nerves II through XII are grossly intact.  No gross deficits.

PHYSICAL EXAMINATION:
VITAL SIGNS:  On admission to the ED today, temperature 98.6, blood pressure 116/74, pulse 96, respiratory rate 18, O2 saturation 98% on room air.
GENERAL:  This is a (XX)-year-old well-developed, well-nourished female in some discomfort but no acute cardiopulmonary distress. She is awake, alert, and oriented x3. She is pleasant and cooperative to the exam.
HEENT:  Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. There is no conjunctival injection or nystagmus appreciable bilaterally. TMs are intact without bulging or retraction. There is no hemotympanum, erythema or drainage in the canals. No tragus or pinna tenderness bilaterally. The nasopharynx is clear. There is no sinus tenderness bilaterally. The oropharynx is clear without erythema, exudate or lesion. Uvula is midline. Airway is patent.
NECK:  Supple, nontender, without lymphadenopathy or thyromegaly. There is no carotid bruit or JVD appreciable bilaterally.
HEART:  Regular rate and rhythm without murmurs, rubs or gallops. Pulses are +2/2, symmetric and intact in the bilateral upper and lower extremities.
LUNGS:  Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The patient is breathing easily without retractions or flaring. Normal inspiratory excursion.
ABDOMEN:  Soft and nondistended, initially sort of diffusely tender across her bilateral lower quadrants and suprapubic region without guarding, rebound or peritoneal signs. She appears to be a little bit more tender, left greater than right, without palpable mass. Good bowel sounds throughout. No CVA tenderness bilaterally.
EXTREMITIES:  Without clubbing, cyanosis or edema.
SKIN:  Intact without rash, lesion or petechiae.
NEUROLOGIC:  The patient has no focal neurologic deficits. Cranial nerves II through XII are grossly intact. Sensation is grossly intact. Following complex commands and moving all four extremities.
PELVIC: Exam is a little bit limited secondary to the patient's discomfort. Pelvic exam is fairly unremarkable. There is no significant discharge within the vault. She does have a palpable and tender left ovary that does not, by my exam, seem overly large and no real tenderness on the right ovary. No cervical motion tenderness and no blood within the vault.

PHYSICAL EXAMINATION:  Vital Signs:  T-max since yesterday, 102.2 degrees.  He is febrile, 101.4 degrees now.  Pulse 62, respirations 21, blood pressure 110/62.  General:  He is a well-built, well-nourished male, lying in bed, not in acute distress.  Alert, awake, oriented x3.  Does no complain of any fever or chills.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round and reactive to light and accommodation.  Extraocular muscles are intact.  Oral mucosa is moist.  Anicteric.  Neck:  Supple.  No JVD, no thyromegaly, no lymphadenopathy.  Trachea is midline.  Lungs:  Clear.  No rhonchi, wheezes or crackle.  Heart:  S1, S2.  I could not appreciate any murmur.  Abdomen:  Soft, nontender.  Bowel sounds are present.  Extremities:  Bilateral lower extremities swollen, down to the ankles and up to the knee, with lymphangitis.  I do not see any open wounds, sores or any tic bites or any bite marks.  Neurologic:  Basically nonfocal.