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Medical Transcription Physical Examination Words and Phrases Part 4

VITALS: Blood pressure 72/44, heart rate 113, respiratory rate 18. The patient is afebrile.
GENERAL: This patient is an elderly female lying in bed, appears to have some dystonic movements of the face. Alert, attentive and oriented x3. The history is provided by her daughters. She denies any pain or any discomfort. She is uncomfortable secondary to diarrhea.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation, 2 mm bilaterally. Horizontal nystagmus was noted at rest. Mucous membranes are pink, pale and dry with a geographical tongue.
NECK: No JVD, no bruits.
LUNGS: There are bilateral rhonchi, in the upper airways more than the lower airways. Full efforts with decreased air entry throughout.
CARDIOVASCULAR: S1 and S2, tachycardic. No murmur appreciated.
ABDOMEN: Soft, flat, nontender. Bowel sounds are hyperactive.
EXTREMITIES: There is no edema, clubbing or cyanosis. There is marked thinning of the epidermis noted with hyperpigmented lesions, mainly of the lower extremities, with slight desquamation of the skin, fragile and friable appearing. Pulses are 2+ of the lower extremities. There are no contractions or open sores noted of the extremities.
NEUROLOGICAL: She is alert, attentive and oriented x3. Cranial nerves II through XII are grossly intact. The patient is hoarse. She is able to move all extremities with no generalized weakness.

PHYSICAL EXAMINATION: The patient appears to be a little anxious. Blood pressure is 193/82, respiratory rate is 17, pulse of 85. HEENT: Sclerae are anicteric. Extraocular movements are intact. Oral mucosa is pink and moist. No deviation of the mouth noted. No nasolabial fold flattening is noted. NECK: Soft and supple. No carotid bruits bilaterally. No cervical lymphadenopathy. No jugular venous distention. LUNGS: Clear to auscultation bilaterally. HEART: S1 and S2 regular rate and rhythm with holosystolic murmur at the right sternal border and an artificial valve click at the left sternal border. ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are present. NEUROLOGIC: She is alert, awake, and responsive. Motor strength is 5/5 in both upper extremities and 4/5 in the right lower extremity and 5/5 in the left. No drifting noted in the upper extremities. There is slight drifting noted in the right lower extremity; left, no drifting noted. EXTREMITIES: No pedal edema bilaterally.

PHYSICAL EXAMINATION: On examination of his right knee, he has a mild to moderate effusion. He comes to full extension, flexes to about 80 degrees. He has tenderness over the patella. He is able to do a straight leg raise without extensive lag or any discomfort. He has no pain on stressing of extensor mechanism. His quadriceps and patellar tendons are intact. He has some slight sensitivity, medial joint line and lateral joint line. He has a negative McMurray’s at this time. He has no evidence of posterior instability. He has no instability to varus/valgus stress. His calves are nontender, negative cords. He is able to flex and extend his foot in his toes.

PHYSICAL EXAMINATION: General: A middle-aged male, lying in bed, alert and awake, slightly lethargic and responds to questions appropriately. Vital Signs: Upon arrival, blood pressure 116/64, pulse of 67, respirations 22, temperature 96.3, and O2 saturation 97%. Pain scale not documented. Glasgow coma scale not documented. Weight 201 pounds. Height 6 feet 3 inches. Head and Neck: Extraocular muscles are intact. Pupils are round and reactive. The patient has mild pallor and slight icterus. No throat congestion. No oral lesions. Ears clear. Neck: Supple. No jugular venous distention. Lungs: Good bilateral air entry. The patient has fine basal crackles. Heart: S1, S2 audible. Regular rhythm. Abdomen: Soft, huge, bulky, and nontender. The patient has evidence of ascites. Extremities: He has bilateral 4+ pitting-type pedal edema. He has redness over his both shins. He has multiple superficial ulcerations in the right lower extremity with slight seropurulent drainage and redness. He also exhibits some tenderness. He does not have any asterixis. Neurologic: He is responsive and oriented x3 at this time.

VITAL SIGNS: Temperature 98.4, blood pressure 146/72, heart rate 105, respirations 22, and O2 saturation 98%.
GENERAL:  The patient is awake and alert, in no distress.
HEENT:  There is no obvious external evidence of trauma. No obvious frank blood. An inspection with the ear speculum reveals a very superficial laceration to the 5 o'clock position of the ear canal, just 0.5 cm from the os. TM itself is intact and there is very minimal blood in the ear canal.
NECK:  Supple.
LYMPHATICS: No localized or regional lymphadenopathy or subcutaneous masses.
CHEST: Chest wall is unremarkable. Breath sounds are clear. No wheezes, rales, or rhonchi. Good inspiratory and expiratory movement. No intercostal retractions.
HEART: Regular rate and rhythm without murmur, gallop, or rub.
ABDOMEN: Bowel sounds are active. Abdomen is soft, nondistended, nontender without masses, hepatosplenomegaly, costovertebral angle tenderness, or palpable abdominal aortic aneurysm.
MUSCULOSKELETAL: Full and complete range of motion. No deformity or sign of trauma.
EXTREMITIES/VASCULAR: Pulses are 2+ and symmetrical. There is no cyanosis, clubbing, edema, calf tenderness. Homans sign is negative.
NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves are intact. Deep tendon reflexes are 2+ and symmetric. Motor is 5/5 bilaterally. Sensation is intact bilaterally. Cerebellar function is normal. Gait is not ataxic. Babinski downgoing bilaterally, and there are no focal deficits appreciated.
PSYCHIATRIC: Normal affect. Eye contact is good. Speech is normal rate and content. Responses are appropriate.
SKIN: Brisk capillary refill. Normal color without rash or lesions.

GENERAL APPEARANCE:  The patient is a well-developed, well-nourished male in apparent distress related to some pain. He is shaking and tremulous on examination, writhing around in the bed.
VITAL SIGNS:  Temperature 98.6, pulse 96, respirations 22, blood pressure 156/98, saturation 98% on room air. Pain is 9/10. GCS of 15.
HEENT:  Head:  Normocephalic and atraumatic. Eyes:  Extraocular motions are intact. Pupils were equal, round, and reactive to light. Tympanic membranes are pearly. Good cone of light. No erythema or exudate. Midline septum. No nasal discharge is present. Mouth and Throat:  Moist mucous membranes. No tonsillar hypertrophy, erythema or exudate.
NECK:  Supple. No lymphadenopathy. No thyromegaly.
HEART:  Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS:  Clear to auscultation bilaterally. No wheezes, rhonchi, or rales.
ABDOMEN:  Soft, nontender, and nondistended. No hepatosplenomegaly. Normal bowel sounds are audible.
EXTREMITIES:  He has had no clubbing, cyanosis or edema. There were 2+ pulses in all four extremities.
BACK:  Examination revealed low lumbar area midline incision that appears to be in good repair.  He did have some tenderness to palpation of the paraspinal muscles in the lumbar area and in the upper back area along the upper trapezius bilaterally. He had no step-off. No spinous process tenderness to palpation on examination.
NEUROLOGIC:  He is alert and oriented x4. Cranial nerves II through XII are intact bilaterally. Strength is 5/5 in all extremities. Intact sensation of all his dermatomes.

PHYSICAL EXAMINATION: This is a well-developed, well-nourished male in no distress, sitting up in bed. There is no stridor. His voice is very hoarse. Vital Signs: Temperature 98.7 degrees, pulse 101, respirations 21, blood pressure 144/62, and O2 saturation was 92% on 2 liters via nasal cannula. HEENT: Head normocephalic. Pupils are equal and reactive to light and accommodation. Conjunctivae are pink. Sclerae nonicteric. Extraocular movements are full. The right and left canals have some mild cerumen. Both tympanic membranes are intact and clear. He has an O2 nasal cannula in place. The nasal septum in deviated to the left side. He has dry nasal mucosa and there is crusting, especially on the right nasal cavity superiorly. There is no epistaxis or lesions. The lip showed no lesions or scars. He has good dentition. The tongue is midline with no lesions. Pharynx is clear. NECK: There is no palpable lymphadenopathy or masses. There is no palpable supraclavicular lymphadenopathy, but there is fullness in the right supraclavicular area. CHEST: Clear to auscultation and percussion.

PHYSICAL EXAMINATION: VITAL SIGNS: When he was first evaluated, he was tachycardic with a pulse of 111 per minute. His temperature was 99.5 degrees Fahrenheit. His blood pressure was 112/72. He was breathing at 20 breaths per minute. He was saturating 95% on 2 liters of oxygen. GENERAL: He was oriented x3 per the daughter. He appeared cachectic with evidence of temporal wasting. HEENT: Normocephalic and atraumatic. Extraocular movements were intact. There was no obvious pallor or icterus noted. NECK: Supple. No evidence of goiter or lymph nodes. LUNGS: There were bibasilar scattered crackles, occasional bronchovesicular breath sounds with end-expiratory wheeze. HEART: S1 and S2 normal. Positive for tachycardia. There was a long systolic murmur best heard in the apex, radiates near the left sternal border and the aortic area. There was no obvious thrill appreciated. Negative for S3. ABDOMEN: Soft with positive bowel sounds. Negative for hepatosplenomegaly. EXTREMITIES: Negative for pedal edema or clubbing. Skin was negative for cyanosis or petechiae. NEUROLOGIC: Grossly within normal limits.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature at the time of examination 97.4 degrees Fahrenheit, heart rate 94, blood pressure 128/75, respirations 18. HEENT: EOMI/PERRLA. External ears and nose within normal limits. No bulging or dull tympanic membranes on exam. Hearing is grossly intact. Oropharynx, no exudates or tonsillar enlargement appreciated. Nasal mucosa pink with no edema or swelling. NECK: Supple to exam with no thyromegaly. LUNGS: Clear to auscultation mostly, except very mild wheezes in the mid lung lobes. Percussion within normal limits. Efforts normal and good. HEART: Regular rate and rhythm without any murmur. No abdominal/carotid bruits were appreciated. Pedal pulses 2+. No edema or no varicosities. ABDOMEN: Soft, nontender and nondistended. On auscultation, bowel sounds present in all four quadrants. Liver and spleen showed no organomegaly. GENITOURINARY: Deferred. LYMPH NODES: No cervical lymphadenopathy was appreciated. SKIN: No rashes or new lesions. NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2+ in biceps, triceps, patellar, and Achilles tendons. Sensation grossly intact and strength 5/5 in upper and then lower extremities bilaterally. PSYCHOLOGICAL: Affect normal, oriented to place, time, and person. Memory good. Judgment and insight intact and good. MUSCULOSKELETAL: Upper extremities and lower extremities were within normal limits for inspection, palpation, range of motion, stability, strength, and tone.