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Medical Transcription Physical Examination Words and Phrases

VITAL SIGNS:  Blood pressure 132/84, pulse 92, respirations 17, temperature 98.5, pulse oximetry 98% on room air.
GENERAL:  The patient is awake, alert and oriented x3, although drowsy.
HEENT:  Normocephalic, atraumatic.  Extraocular muscles are intact.  Pupils are equal, round, and reactive to light bilaterally.  Mucous membranes are moist.
NECK:  Supple.
LUNGS:  Clear to auscultation bilaterally.  No wheezes, rhonchi or rales.
HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.
ABDOMEN:  Active bowel sounds are present.  No rebound, no guarding, no peritoneal signs.
EXTREMITIES:  Without clubbing, cyanosis or edema.
NEUROLOGIC:  Cranial nerves II through XII are intact.  Strength is 5/5.  Gait is normal.  Sensation is intact.  No dysdiadochokinesia or dysmetria.

PHYSICAL EXAMINATION:  GENERAL:  The patient is well developed, thin, in no apparent distress.  She is alert and oriented x3.  VITAL SIGNS:  Blood pressure 142/52 mmHg, pulse regular at 20 beats per minute, respirations unlabored at 20 breaths per minute, and temperature currently afebrile.  HEENT:  Extraocular movements are intact.  Conjunctivae pink.  Mucous membranes are moist.  NECK:  There is no jugular venous distention.  Carotid upstrokes seem normal bilaterally with a very soft bruit auscultated on the right.  Trachea is midline.  There is no thyromegaly.  HEART:  PMI is difficult to appreciate.  First and second heart sounds are regular and of normal intensity.  There is grade 1/6 systolic murmur heard over the left sternal border.  No rubs or gallops are present.  LUNGS:  Scant rales appreciated at the bases bilaterally.  ABDOMEN:  Soft, nontender, and nondistended with normal bowel sounds.  There is no hepatosplenomegaly.  Pulsatile masses not appreciated.  EXTREMITIES:  Negative for cyanosis, clubbing or edema.  Peripheral pulses are +2 throughout.  NEUROLOGIC:  Grossly intact.  No focal deficits.

VITAL SIGNS:  Temperature 98.6, respirations 16, pulse 84, BP 114/78, O2 sat 100% on room air.
GENERAL:  The patient is a well-developed, well-nourished female in no acute distress.
HEENT:  Extraocular muscles are intact.  Pupils are equal, round, reactive to light.  ENT:  Nares patent.  Throat:  No erythema.  Mucous membranes are moist.  TMs are pearly bilaterally.
NECK:  Supple with no lymphadenopathy.
LUNGS:  Clear to auscultation bilaterally with the exception of a few crackles in the right base that clear with cough.
HEART:  Regular rate and rhythm with no murmurs, rubs or gallops.
MUSCULOSKELETAL:  The patient moves all extremities well and ambulates independently.
SKIN:  Warm and dry with no rashes.
PSYCHIATRIC:  The patient is pleasant and cooperative with an appropriate mood and affect.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Blood pressure:  122/78.  Pulse:  81, regular.  GENERAL:  He is a well-nourished, well-developed (XX)-year-old male complaining of 7/10 chest pain, who appears acutely ill.  HEENT:  Eyes:  No scleral icterus.  No xanthelasma.  Mouth:  No oral pallor or cyanosis.  NECK: Carotid pulses are full and without bruit.  CHEST:  Clear to auscultation and percussion.
CARDIAC EXAM: Cardiac impulse feels normal. Heart sounds are distant.  ABDOMEN:  Soft, nontender.  EXTREMITIES:  No edema, no varicose veins.  CENTRAL NERVOUS SYSTEM:  Oriented x 3.  SKIN:  Cool and dry.

VITAL SIGNS:  Blood pressure 124/79; pulse was recorded by triage as 122, pulse retaken by myself was 108; respirations 19, temperature 101.5.
GENERAL:  The patient is alert and oriented x3, in no apparent distress.
HEENT:  Normocephalic and atraumatic.  Extraocular muscles are intact.  Pupils are equal, round, and reactive bilaterally.  Tympanic membranes are intact, nonerythematous and nonbulging.  Oropharynx is with some slight erythema, mild edema to the tonsillar pillars and uvula.  No exudate, no submandibular anterior or posterior auricular lymphadenopathy.
NECK:  Supple.
LUNGS:  Clear to auscultation bilaterally.  No tachypnea.  No difficulty breathing.
HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.
ABDOMEN:  Soft and nontender.  No splenomegaly, no hepatomegaly, no peritoneal signs, no rebound or guarding.
EXTREMITIES:  Without clubbing, edema or cyanosis.
SKIN:  There are no rashes noted.
NEUROLOGIC:  Intact and nonfocal.

PHYSICAL EXAMINATION:  Vital Signs:  Temperature 99.6, blood pressure 156/98, pulse 114, O2 saturation 94%.  General:  She is a slightly overweight woman in some distress.  HEENT:  Head is normocephalic, atraumatic.  Pupils are equal, round, and reactive to light and accommodation.  EOMs are full.  External ears are clear.  Hearing is intact.  Nasal mucosa is moist.  Neck:  Supple.  Trachea is midline.  Thyroid is not enlarged.  Lungs:  Clear posteriorly, perhaps some dullness in the bases.  Cardiovascular:  Regular rate and rhythm.  There is a murmur.  Breasts:  Not examined.  Abdomen:  Soft, nontender, nondistended.  Hernias are not present.  Genitourinary:  Deferred.  Lymphatic:  Lymph nodes are not present in the neck, axilla nor groin.  Musculoskeletal:  She has a full range of motion, good muscle bulk and tone of all her extremities.  Skin:  Clear.  There are no pressure wounds.  Neurologic:  Nonfocal.  Cranial nerves are intact.  Psychiatric:  She does appear to be a little bit morose.

VITAL SIGNS:  Blood pressure is 142/84 with a pulse rate of 97, respiratory rate of 20, temperature of 98.6, and O2 saturation of 97%.
GENERAL:  The patient is alert and oriented x4, in no acute distress. Does not appear toxic or ill.
HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are fully intact.  Oropharynx is clear.  No erythema.  Uvula is midline.  Tonsils are inflamed with a slight amount of exudate.  Palate is even.
HEART:  Regular rhythm.  No murmur, rub or gallop.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, and nondistended with positive bowel sounds.
EXTREMITIES:  Have no clubbing, cyanosis or edema.
PSYCHIATRIC:  The patient is alert and oriented x4.
VASCULAR:  Has good pulses throughout.
LYMPHATICS:  The patient does have lymphadenopathy along the anterior cervical chain.
SKIN:  Warm, dry, and intact.

GENERAL:  This is a pleasant male in no acute distress.
VITAL SIGNS:  Blood pressure 114/86 and pulse 82.  Afebrile.
HEENT:  Sclerae anicteric.  Pupils are equal and reactive.  Oropharynx clear.  Tongue normal size.
NECK:  Supple.  No adenopathy or thyromegaly.  Carotids 2+ and symmetrical.
LUNGS:  Clear to auscultation and percussion.  Negative spinal tenderness.  Negative CVA tenderness.
ABDOMEN:  Soft.  There was no distention.  No guarding, rigidity, organomegaly or masses.  Normal bowel sounds without tympany.  There was mild to moderate epigastric tenderness to deep palpation.
EXTREMITIES:  Femoral pulses 2+, symmetrical.  No clubbing, cyanosis or edema.  Distal pulses 2+, symmetrical, dorsalis pedis and posterior tibial.
NEUROPSYCHIATRIC:  Alert and oriented x3 without focal defects.

GENERAL:  The patient is well developed, well nourished and in no acute distress.
VITAL SIGNS:  Weight 201 pounds; height 5 feet 6 inches; BP 153/92, left arm, and 140/86, right arm; pulse 82 and regular; respirations 18 and unlabored.
HEENT:  Normocephalic and atraumatic.  PERRL.  EOMI.  No lid lag, no exophthalmos, no xanthelasma, conjunctivae pink, no scleral icterus.  Ears and nose externally normal.  Pharynx normal.  Has upper dentures.
NECK:  No JVD.  No carotid bruit, no thyromegaly, no adenopathy.
CHEST:  Lungs clear.  Breath sounds normal bilaterally.
HEART:  PMI in the fifth intercostal space, no lift or thrill.  S1 and S2 normal.  No gallop, murmur or rub.  Had 2/6 systolic ejection murmur diffusely, both at the base and at the apex.
ABDOMEN:  Soft and nontender.  Normal bowel sounds.  No bruit.  No palpable aortic aneurysm, mass or organomegaly.
EXTREMITIES:  Full range of motion.  No cyanosis, clubbing, trace edema. 
MUSCULOSKELETAL:  No gross joint deformity or swelling.
NEUROLOGIC:  Alert and oriented x3.  Cranial nerves intact.  Balance, gait, and coordination normal.  Normal affect.
SKIN:  No significant skin lesions or rashes.
PSYCHIATRIC:  Mentation normal.

PHYSICAL EXAMINATION:  Reveals a well-developed, well-nourished female who is in no acute distress.  Her vital signs are stable.  Respirations are 20.  Head, eyes, nose, and throat are within normal limits.  Lungs are relatively clear.  Some decreased breath sounds at the bases.  Heart revealed no murmur, gallop or rub.  Abdomen is not significantly distended.  Bowel sounds are present.  There is a scar from the xiphisternum all the way down to the lower pelvis.  It was not significantly tender.  There were two small incisional hernias that were not incarcerated.  No organomegaly or masses.  No bruits in the abdomen.  Extremities reveal no clubbing, cyanosis or edema.  Rectal reveals nonimpacted stool which is Hemoccult negative by my testing.  Neurologic is grossly intact.

PHYSICAL EXAMINATION:  General:  The patient is drowsy.  He is arousable.  He is unable to answer questions.  He is not moving the left half of his body.  Vital Signs:  His pulse on arrival was 76, blood pressure was 129/66, respirations normal, and temperature normal.  HEENT:  Normocephalic.  No pallor, jaundice or xanthelasmata.  Neck:  Supple.  Arterial and venous pulses were normal.  Chest:  Vesicular breathing with slightly prolonged expiration.  Heart:  Regular, first normal, and second split normally.  There is a soft murmur, 1/6, apex.  There is no rub.  Abdomen:  Soft and nontender.  No rebound tenderness, organomegaly or ascites.  Normal bowel sounds.  Extremities:  Shows no edema.  Neurologic:  There is left hemiplegia.

GENERAL:  Well-developed, well-nourished white female in no acute distress.  Alert and oriented x3, nontoxic in appearance.  The patient is ambulatory in the emergency department.
HEENT:  Noncontributory to exam.
NECK:  Supple without lymphadenopathy.  No JVD or bruits noted.
HEART:  Regular rate, regular rhythm without murmurs, rubs or gallops.
LUNGS:  Clear to auscultation bilaterally without wheezes, rales or rhonchi.
ABDOMEN:  Soft and nontender.  No rebound, no guarding, no hepatosplenomegaly, no masses noted.
BACK:  Negative CVA tenderness.
EXTREMITIES:  The patient has 2+ pulses in all extremities.  Full range of motion of all extremities.  No ecchymosis, edema, erythema, clubbing or cyanosis noted on the left side, but in the right upper extremity, the patient does have positive edema to her entire arm.  It is cold to touch and pale in color.  The patient also has positive bruising on the medial aspect of the humerus and the forearm.  She has full range of motion but complains of pain in the elbow with range of motion.
SKIN:  Warm and dry to touch, except to the right arm.  The patient's entire right arm is cold to touch and pale in color.
NEUROLOGIC:  The patient is alert and oriented x3.  The patient has 5/5 strength in all extremities, 2+ deep tendon reflexes, equal, throughout extremities.  Gross sensation to touch is intact.  Cranial nerves II through XII grossly intact.

VITAL SIGNS:  On physical exam today, the patient had a pulse of 74, blood pressure 132/85, respiratory rate of 17.
GENERAL:  The patient is a well-developed, well-nourished female in no apparent distress.
HEENT:  EOMI.  PERRL.  No conjunctival erythema.  No scleral icterus.  External Ears and Nose:  No evidence of lesions or trauma.  Oropharynx is clear and moist.
NECK:  Supple, 2+ carotids bilaterally.  No bruits.  No lymphadenopathy.  No JVD.  No thyromegaly.
LUNGS:  Clear to auscultation and percussion.  Normal respiratory effort.
HEART:  Regular rate and rhythm.  S1 and S2.  No S3 and S4.  No murmurs, rubs, or gallops.
ABDOMEN:  Bowel sounds positive, soft, and nontender.  She had no hepatosplenomegaly.
EXTREMITIES:  She has no lower extremity edema.
NEURO:  Alert and oriented x3.  Strength 5/5 bilaterally on upper and lower extremities.  Sensation intact grossly to light touch and pinprick.  No evidence of dysmetria on finger-to-nose.   No shuffling and no wide-based gait. 
PSYCH:  Alert and oriented x3, mood good, no flat affect.
MUSCULOSKELETAL:  Gait and station is somewhat awkward.  She did have some trouble getting around.

PHYSICAL EXAMINATION:  Temperature:  Afebrile.  Vital signs are stable.  The pupils are equal, round, and reactive to light and accommodation.  Extraocular muscle function is intact.  The sclerae are clear.  There is no mucosal pallor or mucositis.  The tympanic membranes are intact.  The nose is patent.  The oropharynx reveals no erythema or edema.  The tongue is midline.  No sinus tenderness.  The neck is supple without masses.  The trachea is midline.  The carotid pulses are full with no overlying bruit.  There is no thyromegaly.  There is no cervical, supraclavicular, axillary or inguinal adenopathy.  The cardiac exam reveals a regular rate and rhythm without murmur, rub or gallop.  The lungs are clear to auscultation and percussion.  The abdomen is soft and nontender.  No hepatomegaly, splenomegaly, tenderness, mass or ascites.  Extremities with arthritis.  The neurologic exam reveals no cognitive dysfunction, focal neurologic deficits, pathologic reflexes, cerebellar signs or gross sensorimotor deficits.  The cranial nerves II through XII appear grossly intact.  The skin is normal with no suspicious lesions or rash.

PHYSICAL EXAMINATION:  GENERAL APPEARANCE:  The patient is alert and oriented, not in any acute respiratory distress.  VITAL SIGNS:  Afebrile.  Pulse is 82 per minute, respiratory rate is 21 per minute, and blood pressure is 126/70.  HEENT:  PERRLA.  EOMI.  No icterus.  NECK:  Supple.  There are bilateral lymph nodes palpable on both sides of the cervical area.  No enlarged thyroid.  No JVD.  Mucous membranes are normal.  HEART:  S1 and S2 regular.  No murmur heard.  CHEST:  Bilateral air entry.  No rhonchi, no rales.  ABDOMEN:  Soft and nontender.  Liver and spleen clinically not palpable.  Bowel sounds are present.  No guarding, no rigidity, and no rebound.  EXTREMITIES:  Left extremity positive for edema.  Bilateral pulses are seen.  Petechiae are seen on the left lower extremity.  BACK:  No local tenderness.  No CVA tenderness.  NEUROLOGIC:  No focal deficit.  SKIN:  Other than the petechial rash on the legs, no other skin or ecchymotic lesions seen.  LYMPH NODES:  Enlarged lymph nodes are palpable in the cervical area, both axillary areas, and left inguinal area.  Lymph nodes are not matted and nontender.  No overlying erythema, and all the lymph nodes are mobile.

GENERAL:  A well-developed, well-nourished white man in no acute distress.
VITAL SIGNS:  Blood pressure is 154/60, heart rate is 80 and regular, respiratory rate 20 and unlabored, and temperature is afebrile.
SKIN:  Without rashes.
HEENT:  Normocephalic and atraumatic.  The conjunctivae are anicteric.  The oropharynx is without lesions or exudate.  The tongue is midline.  The gag is intact.  Poor dentition is noted.
NECK:  Supple.  Full range of motion.  No thyromegaly or adenopathy.  Carotids are 2+ without bruits.  There is mild JVD appreciated.
CHEST:  Reveals decreased breath sounds at the left base with egophony appreciated.  No rales, rhonchi, or wheezes.  There is decreased, but symmetric air expansion.
HEART:  Regular rate and rhythm.  Normal S1 and S2.  No murmur, rub, or gallop appreciated.
ABDOMEN:  Soft, nontender, and nondistended.  No hepatosplenomegaly.  No rebound or guarding.
EXTREMITIES:  Demonstrate 1-2+ pitting edema with greater edema appreciated in the left lower extremity.  No palpable cords.
NEUROLOGIC:  Grossly nonfocal with no lateralizing motor deficits.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Currently, her blood pressure is 160/94, temperature 96.4, respiratory rate 22, and pulse oximetry 98% on room air.  HEENT:  Conjunctivae are clear.  Oropharynx is slightly dry but clear.  LUNGS:  Clear.  NECK:  No lymphadenopathy in the neck or supraclavicular region or axillary region.  No evidence of lumps in the breasts or nipple discharge.  HEART:  Regular rate and rhythm.  ABDOMEN:  Soft and nontender without hepatosplenomegaly.  EXTREMITIES:  Muscle strength is 5/5 proximally and distally in the extremities.  DTRs are +2 at the elbows and zero at the Achilles.  Babinski equivocal.  Pulses are decreased, PT and DP.  There is evidence of chronic erythema of the skin above the medial malleolar, on the left.  It is nontender.  Evidence of mild OA changes of the hands, knees, arms, and feet.  There is marked tenderness of the lower thoracic upper lumbar region.  There is evidence of marked kyphosis of the thoracic spine.

VITAL SIGNS:  Stable. She is afebrile with temperature of 98.5 and blood pressure of 154/95.
HEENT:  Showed no scleral or conjunctival inflammation. Her oral mucosa was moist without lesions.
NECK:  Supple without lymphadenopathy or thyromegaly. The carotid upstrokes were 2+. She had no salivary gland swelling or tenderness. Her carotids were nontender with no bruits. She had no supraclavicular or infraclavicular bruits. The temporal arteries were nontender and nonnodular with normal pulsations. Radial and dorsal pedal pulses were 2+.
LUNGS:  Had no rales, rhonchi, or wheezes.
CARDIAC:  Had no murmur.
ABDOMEN:  Nontender without organomegaly. It was somewhat distended and misshapened after her colectomy.
SKIN:  Had no rash. She had onychomycosis but no nail pitting. She had no nail fold capillary changes. No sclerodactyly. She had scalp alopecia but was wearing a hair piece. She had no subcutaneous nodules or gouty tophi.
NEUROLOGIC:  Grossly intact.
MUSCULOSKELETAL:  Notable for some pain with palpation of the posterior neck musculature and diminished range of motion in the neck. The spine was nontender. Shoulders, elbows, and wrists were normal. The left third DIP, left second PIP, and right fourth PIP had swelling, tenderness, and erythema. The right third MCP had a small nodule which was significantly tender. Her right hip had significant pain with active flexion. Passive range of motion of hip while not full was not nearly as painful. Both knees had osteoarthritis with no active synovitis. Her ankles were not tender. All of her toes had cock-up deformities with no active synovitis.