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Physical Exam Normal Template Sample / Transcription Examples

GENERAL:  The patient is a well-nourished, middle-aged Caucasian female, not in any obvious distress.
VITAL SIGNS:  Temperature 98.6 degrees Fahrenheit, blood pressure 132/64, pulse 104 and respirations 22.
HEENT:  Remarkable for pallor. There is no icterus. Sclerae are clear. Pupils are equal and reactive to light. Mucous membranes are moist. There are no oropharyngeal lesions.
NECK:  Supple. No lymphadenopathy. Thyroid is not palpable.
CHEST:  Clear to auscultation.
HEART:  Regular rate and rhythm.
ABDOMEN:  Obese and soft with large infraumbilical oval wound measuring approximately about 5 cm to 7 cm in length and about 4 cm in broadest diameter with lobulated granulation tissue in the base. There is no discharge. There is no necrosis. There is undermining all around. There is no surrounding erythema or induration. The skin around the wound is minimally tender.
NEUROLOGIC:  Nonfocal.
EXTREMITIES:  Distal pulses are not felt.

VITAL SIGNS:  Temperature 98.6 degrees, heart rate 102 beats per minute, respiratory rate 22 breaths per minute, blood pressure 146/52 mmHg and oxygen saturation 97% on 3 liters per nasal cannula.  Weight is 67.5 kilograms.
GENERAL:  The patient is alert, responsive, well developed and well nourished, resting comfortably in bed.  No acute respiratory distress is appreciated at this time.  Mild anxiousness is appreciated.
BACK:  No CVA or spinal tenderness.
LYMPH NODES:  No lymphadenopathy noted in the head and neck regions.
SKIN:  Warm, dry, no visible erythema, rashes or cyanosis.
NECK:  Supple.  Full range of motion.  No jugular venous distention.  No carotid bruits auscultated.  No tenderness.  No thyromegaly.
HEENT:  The patient's head is normocephalic to inspection.  Pupils are equally round and reactive to light and accommodation.  Extraocular movements are intact.  No conjunctival redness or scleral icterus appreciated.  Hearing acuity is grossly intact.  Nares are patent with dry nasal mucosa. Tongue is midline without fasciculations.
RESPIRATORY:   The patient's breath sounds are diminished but fairly clear throughout lung fields bilaterally.  No wheezing, crackles or rubs appreciated at this time.
CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1, S2.  No S3 or S4 noted.  No murmurs or rubs are appreciated.
ABDOMEN:  Good bowel sounds, soft and nontender.  No appreciated hepatosplenomegaly.  No masses palpated.  No bruits auscultated. 
EXTREMITIES:  Good range of motion.  Good pulses.   Trace pedal edema is appreciated.  No calf tenderness.  No palpable cords. 
NEUROLOGIC:  The patient is alert and oriented to person, place and time.  Cranial nerves II through XII are grossly intact.  Sensation is normal.  Strength is 5/5, motor, in all extremities. Normal mood and normal affect is appreciated.  No focal neurological deficits are noted.

PHYSICAL EXAMINATION:  On examination, neurologically, the patient is conscious, alert and well oriented. Speech is normal. Mildly impaired recent memory. Other cognitive functions are normal. Cranial Nerves:  Pupils are equal, reacting to light and accommodation. Visual field is normal. Extraocular movements normal. No facial asymmetry. Normal movement of tongue, palate, jaw, uvula. The rest of the cranial nerves are normal. Speech is normal for age. No nominal aphasia. Motor Examination:  The patient has weakness of the distal muscles of the feet. The weakness is 4.5/5 and the left upper limb is normal. Right upper limb shows weakness of all muscles innervated by radial nerve sparing triceps muscle. The extensors of the wrist are 0/5. Intrinsic muscles of the hands and muscles innervated by median and ulnar nerves are normal. Sensory Examination:  Mildly decreased pinprick in the hand, in the distribution of the radial nerve. The sensory examination in the posterior antebrachial cutaneous nerve is normal. Triceps muscle is normal. Ankle jerks 1+ medial hamstring, 0 to 1+ patella. Left triceps is 1+, biceps is 1+, supinator absent. Right supinator and triceps are absent and biceps is 1+. Position and vibratory senses are normal for age. Cortical sensations are normal. Cerebellar exam is normal for finger-to-nose and heel-to-shin test. Gait not tested. Neck is supple. Carotid showed no bruits. HEENT:  Negative. S1, S2. No pedal edema. Bilateral inguinal hernia. Abdomen is soft, nontender. No organomegaly. 

VITAL SIGNS:  Temperature 98.4, pulse 80, respirations 21 and blood pressure 132/64. Oxygen saturation is 98% on 6 liters of oxygen. Height 5 feet 8 inches and weight 214 pounds.
GENERAL APPEARANCE:  A well-developed, well-nourished gentleman who was in no acute distress. His affect was normal.
NECK:  There were no carotid bruits.
LUNGS:  Had bibasilar rales. Had decreased respiratory effort.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Protuberant. Bowel sounds were positive. It was nontender.
EXTREMITIES:  Minimal ankle edema. No clubbing or cyanosis. No calf erythema, warmth or tenderness. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout. Vein graft harvest sites were clean, dry and intact.
NEUROLOGIC:  The patient was alert and oriented x3. Immediate recall was 3/3 and 2/3 after 5 minutes. His speech was fluent without dysarthria. His voice was dysphonic. He could follow instructions without difficulty. Basic problem solving, reasoning and attention were intact. Extraocular movements were intact. Visual fields were full. Smile was symmetric. Hearing was intact bilaterally. Shoulder shrug was symmetric. His tongue protruded in the midline with good lateral movement. Tone was normal. No atrophy was noted. Strength was generally 3/5 throughout without focal motor deficits. Ankle jerks and knee jerks were absent bilaterally. Toe response was downgoing bilaterally. Upper extremities were 1+ throughout. Finger-finger-nose and heel-knee-shin were slow, but intact. Localization was intact. Gait was not applicable at this time.

GENERAL:  The patient is a well-developed, well-nourished female in no apparent distress.
VITAL SIGNS:  Temperature 98.6, pulse 88 and the blood pressure 124/56.
NECK:  Supple.
NEUROLOGIC:  The patient was alert and oriented to person, place and time. The speech was clear and the language was fluent with normal naming, repetition, comprehension and vocabulary. Examination of the cranial nerves revealed full visual fields, intact extraocular movements, equal, round and reactive pupils, and benign fundi. The facial sensation was full and the face was symmetric. The patient was able to hear a finger rub bilaterally. The palate rose symmetrically. Shoulder shrug was symmetric and the tongue protruded in the midline. On motor examination, the bulk and tone were normal. Motor strength was 5/5 throughout with the exception of left dorsiflexion, which was 3/5. There was no drift. Some tremor was present in the upper extremities. Deep tendon reflexes were 2+ throughout with the exception of the right ankle jerk, which was 1+. The right plantar response was flexor, and the left was questionably extensor. Sensations were intact to light touch, proprioception and vibration. Coordination was intact to finger-to-nose and heel-to-shin testing. The patient's gait was not evaluated.

GENERAL:  The patient is alert and oriented x3.
VITAL SIGNS:  Temperature 97.6, blood pressure 127/69, pulse 72, respiratory rate 18. The patient is on nasal oxygen, 2 liters, with saturation more than 92%.
HEENT:  Overall unremarkable. Hearing deficit. 
LUNGS:  Air entry, basal, diminished.
HEART:  S1, S2, regular.
ABDOMEN:  Soft, nontender, morbid obesity. Bowel sounds present.
EXTREMITIES:  No calf tenderness. Clinically, no sign of DVT. Mild edema. Dorsalis pedis and posterior tibial pulses palpable.
NEUROMUSCULAR:  Good functional range of movement of the shoulders and overall no focal deficits. Reflexes are intact. Lower Extremities:  Right hip total hip arthroplasty. Operative wound covered with dressing. Right lower extremity:  Active SLR not possible, but good active ankle dorsiflexion. Left lower extremity:  Good active SLR, good active ankle dorsiflexion. Lower extremity reflexes difficult to elicit. Gross sensation is intact. No severe dysesthesias at this time. Plantars downgoing.  Proprioception is intact.