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Medical Transcription Physical Examination Examples

PHYSICAL EXAMINATION:  General:  The patient is pleasant, tends to be cooperative, appears much older than her stated age.  Her body habitus is ectomorphic and she is mildly asthenic.  Vital Signs:  Currently stable.  The patient is afebrile.  Skin/Extremities:  No skin rashes or lesions are noted.  No cyanosis, clubbing or edema in the extremities.  Head and Neck:  The head is normocephalic and atraumatic.  The head and neck are nontender without thyromegaly or adenopathy.  Carotid upstrokes are 1+/4.  No cranial or cervical bruits.  Neck:  Supple with a full range of motion.  Negative Brudzinski and Kernig's maneuvers.  Heart:  Regular rate and rhythm.  Lungs:  Clear to auscultation.  Abdomen:  Soft and nontender.  Back:  Postoperative scar noted.  Neurologic:  Higher cortical function-mental status:  The patient is alert.  She is oriented x3 to time, place, and person.  There is no gross evidence of aphasia, apraxia or agnosia.  Her recent and remote memory appear intact as she has an average fund of knowledge.  Cranial Nerves:  Pupils 4 mm, reacting briskly to 2 mm without afferent pupillary defect.  The visual fields are intact to confrontation testing.  Funduscopic examination revealed sharp disk margins with normal vasculature.  No papilledema, hemorrhages or exudate.  Extraocular movements are full and smooth with normal pursuits and saccades.  No nystagmus was noted.  The face is symmetric.  Remainder of cranial nerves are intact and symmetrical.  Strength, +4/5 diffusely with the exception of the left lower extremity.  Left lower extremity approximately +4/5, left lower extremity distally +4/5.  Tone and bulk appear normal.  No involuntary movements noted.  Reflexes:  1 to 2/4 and symmetrical in the upper and lower extremities with the exception of the Achilles responses, which are absent bilaterally.  Plantar responses are downgoing bilaterally.  Sensation:  Intact to pinprick, light touch, vibration, and proprioception.  Coordination:  The patient normally performs finger-to-nose-to-finger, heel-to-knee-to-shin and rapid alternating movements in a symmetrical fashion.  Gait and Station:  The patient walks with a narrow-based gait.  She is able to heel-toe and tandem walk forwards and backwards with minimal difficulty.  She mildly circumducts her left lower extremity particularly on turns.  Romberg and monopedal Romberg are negative.

PHYSICAL EXAMINATION:  The patient is obese.  At this time, she is not acutely toxic.  She does report pain in her legs bilaterally.  HEENT:  Pupils are round and reactive bilaterally.  Sclerae anicteric.  Conjunctivae noninjected.  Oral mucosa is moist.  No thrush or pharyngitis.  Neck:  Supple.  Trachea midline.  No palpable thyromegaly.  Lymphatics:  No frank cervical or supraclavicular adenopathy.  No frank inguinal adenopathy, although the patient's body habitus limits evaluation somewhat.  Chest:  Symmetrical excursion.  Lungs are clear to auscultation without wheezes.  Heart:  Regular rhythm at this time.  No rub evident.  Positive systolic murmur at lower sternal border.  Abdomen:  Normoactive bowel sounds.  No guarding.  No rebound tenderness.  No palpable hepatomegaly.  The patient is overweight.  Extremities:  The patient does have some excoriations in her forearms and arms bilaterally.  By her description, these are areas where she thought she may have had mosquito bites, scratched, it is quite extensive, but there was no apparent cellulitis in the upper extremities.  On the lower extremities, the patient does have edema bilaterally.  On the left, the patient has blistering involving the legs, much of this is ruptured.  A small amount of clear fluid was expressed, which will be sent for Gram stain and culture from the leg.  I also cultured a similar site on the left great toe.  There is erythema involving the foot, the toe, and the leg on the left.  On the right, there is also erythema involving the toes.  There was not any active blistering at this time, but the patient states there had been some blisters on the toes before.  There is, however, erythema involving the thigh, particularly on the medial aspect.  There did not appear to be any specific lymphangitic streaks.  There was no foul odor.  No apparent crepitance.  There is tenderness to palpation in the involved areas.  In addition, the patient has numerous excoriated lesions, similar to what was on her upper extremities, on her legs and thighs bilaterally.  She had spontaneous movement of her upper and lower extremities bilaterally.

PHYSICAL EXAMINATION:  The patient's temperature is 97.4 degrees, pulse is 66, respiration is 22, and blood pressure is 154/92.  General:  This is an obese white female who is tearful at times during exam.  Neurological:  The patient is alert and oriented to person, place, and time.  Her speech is fluent and language is intact.  Short-term and long-term memory appears to be adequate.  The patient's cervical range of motion is decreased bilaterally, laterally.  There is no meningeal sign or Lhermitte sign.  Cranial Nerve Exam:  Pupils are equal and reactive at 3 mm and brisk.  Extraocular muscles are intact.  Visual fields are intact.  Accommodation is intact.  Corneal reflex is intact.  Hearing is intact to finger rub.  There is no facial asymmetry and tongue is midline with good palate elevation.  Motor exam reveals the patient has generalized weakness, distally greater than proximal, 4/5 and distal 4- to 3/5.  This weakness is nonfocal.  The patient does have an intentional and postural tremor noted in bilateral upper extremities.  There is no bradykinesia, rigidity noted or resting tremor.  The patient's deep tendon reflexes are symmetrical and there is no Babinski.  The patient has no pronator drift, fasciculations or atrophy.  Her Romberg is positive with retropulsion.  The patient is unable to tandem gait and her wide-based gait is grossly steady, although the patient could not walk for a very long distance.  The patient's fine motor coordination is intact with finger-to-nose and heel-to-shin testing.  Sensory exam revealed the patient to have no decreased sensation to light touch or pinprick.  She did have decreased sensation to temperature in the right upper extremity and left V2 region.  There is no extension.  Cardiovascular:  S1 and S2 are regular.  Respiratory:  The patient has no rales or wheezing noted.

PHYSICAL EXAMINATION:  Today shows that her visual fields are full. Extraocular eye movements are intact. Neck dystonia, as described above, she has severe orolingual dystonia with forced mouth opening and extrusion of the tongue with the need to hold the tongue back constantly. There is little mobility of the neck with spasms in the scalene, especially on the left side trapezius, sternocleidomastoids bilaterally. She is able to move the hand, but does have dystonic posturing with flexion of the fingers and the wrists and elbows, restricted movement in the shoulders, but her strength seems at baseline. She can point with the index fingers on a signboard and express her needs. Her memory and her cognition judged indirectly are relatively intact and always have been. She has severe dextroscoliosis and tilting of her trunk sideways and forward. There seems to be severe spasms in the paraspinals and lumborum on the left side and perhaps obliques on the left side far more than the right. There is relatively good strength in the right lower extremity, but clear weakness at least 3 to 4/5 in all the muscles of the left lower extremity with hyperreflexia. She seems to have sensation in all her extremities.

PHYSICAL EXAMINATION: Vital Signs: Pulse 64 and regular, respirations 18 and nonlabored, and blood pressure 142/85. General Exam: We have a pleasant, cooperative male who appears to be his stated age. He is in no acute distress. HEENT: Normocephalic and atraumatic. The pupils are equal, round, and reactive to light. Sclerae and conjunctivae are anicteric.  Funduscopic is deferred. Oropharynx Exam: Notes moist mucous membranes. Tongue protrudes in the midline. Posterior pharynx is clear. Dentition is satisfactory. Neck: Supple. There is no thyromegaly or mass. The trachea is midline. The carotid upstroke is 2+. No bruits auscultated. No jugular venous distention. Chest: Symmetrical without obvious deformity. Breath sounds are clear to auscultation. Respiratory pattern is nonlabored. Heart: There is a regular rate and rhythm. PMI is nondisplaced. Normal S1. Normal S2. No extracardiac sounds were auscultated. Abdomen: Soft and nontender. No mass or bruits. Bowel sounds are present and normal in all quadrants. Genitorectal: Deferred due to the patient's left main coronary artery stenosis. Extremities: Acyanotic, there is no clubbing or edema. Saphenous veins are intact without obvious varicosities. Pulses: DP/PT 1+ bilateral. Skin: Dry and warm. No rash or hives. Lymphatic: No axillary, cervical lymphadenopathy. Neurologic: Alert and oriented. Normal affect. Nonfocal exam.

PHYSICAL EXAMINATION: Vitals: Blood pressure 125/64, heart rate 86, respiratory rate 22, and temperature 97.6 degrees. General: The patient does not appear to be in acute distress at the present time. HEENT: Head normocephalic and atraumatic. Pupils equal, round, reactive to light and accommodation. Extraocular muscles are intact. Conjunctivae pink. Sclerae nonicteric. Funduscopic exam not performed. Otoscopic exam not performed. Mouth mucosa moist. Neck: Obese, no jugular venous distention. Normal carotid upstrokes bilaterally, no carotid artery bruits, no gross thyromegaly on palpation. Chest: Obese. No tender spots or deformities. Heart: Point of maximal impulse could not be determined due to obesity. Irregular rhythm. There is no gallop. There is mild 1/6 systolic murmur at the left sternal border. Apparently, the echocardiogram probably revealed mild mitral regurgitation and 2+ aortic regurgitation. Abdomen: Obese, soft, bowel sounds positive. No organomegaly. Extremities: The patient has mild bilateral feet, ankles, and shin edema. No cyanosis or clubbing. Pulse is palpable in the upper extremities and distal leg pulses decreased. Neurologic Exam: The patient answers questions appropriately. She moves all four extremities. There are no acute neurological focal symptoms.