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Physical Examination Transcribed Medical Transcription Samples

GENERAL:  The patient is a super-morbidly obese male, in no apparent distress.
VITAL SIGNS:  Pulse 76, respirations 14, blood pressure 132/72. Height 5 feet 8 inches, weight 355 pounds, BMI 54.
HEENT:  PERRLA. Sclerae anicteric. Oral cavity:  Moist, pink, 1+ tonsillar hypertrophy without exudate, erythema, crypts or obstruction.
NECK:  Supple. No JVD, adenopathy or thyromegaly.
LUNGS:  Clear to bases bilaterally.
HEART:  RRR. No S3, S4, murmur or carotid bruits.
ABDOMEN:  Centrally obese with positive bowel sounds in all quadrants. Organomegaly not appreciated secondary to body habitus. No tenderness, masses or rebound.
RECTAL:  Exam deferred.
PERIPHERAL VASCULAR:  Extremities warm and dry, 1+ pitting edema from mid shin to ankles bilaterally with early brawny hyperpigmentation about the ankle areas. No varicosities or cords.
MUSCULOSKELETAL:  Full ROM of all the major joints.

GENERAL:  The patient is a pleasant young woman in no acute distress.  She is alert and oriented x3.
HEENT:  No scleral icterus.
NECK:  Trachea is midline.
LUNGS:  Clear to IPPA.
HEART:  Heart sounds are normal.
LYMPH NODES:  There is no cervical, supraclavicular or axillary adenopathy.
BREASTS:  Both breasts are normal.  No masses are palpable.
ABDOMEN:  There is no hepatosplenomegaly, inguinal adenopathy or other abdominal pathology noted.

PHYSICAL EXAMINATION:  Blood pressure 144/70, pulse 76 and regular, respiratory rate 16.  The patient is oriented to place and time.  She had some attentional problems.  Mild memory difficulty; she was able to remember 2/4, she did not recall the other two.  There is a hint of apraxia.  She can conceptualize multi-step commands.  She is rather inattentive and has some word finding difficulties and difficulties naming uncommon objects. Funduscopic examination is normal.  Visual fields, extraocular eye movements are full.  There is no nystagmus.  There is a profound hearing loss on the right and somewhat on the left.  There is no ptosis.  Facial movements are normal.  Tongue and palate are normal.  There is no evidence of motor weakness or drift.  Deep tendon reflexes +2 in the upper extremities and at the knees, absent at the ankles.  Fine/coarse motor movements are normal.  There is no limb dysmetria.  She has an ankle foot orthotic.  There is no evidence of ocular or cervical bruits.  There is no temporal tenderness. 

VITAL SIGNS:  Blood pressure 142/90, pulse 86, respiratory rate 18. Pain level 0/10.
GENERAL:  The patient is a pleasant woman, well developed, in no acute distress.
NECK:  Supple, no bruits.
HEART:  Regular rhythm.
EXTREMITIES:  No edema was noted.
NEUROLOGIC:  Alert and oriented x3. Normal attention and language. No neglect or apraxia was noted. Pupils about 4 mm, both reactive to light. Full visual fields to confrontation. No visual extinction to double simultaneous stimulation. Disks sharp bilaterally. Extraocular movements intact with no nystagmus. Facial sensation and strength normal. Normal hearing bilaterally. Normal shoulder shrug. Tongue midline. Motor strength 5/5 throughout without any pronator drift. Normal muscle tone. No abnormal movements noted. No dysmetria on finger-to-nose or heel-to-shin test. She had initially some mild tremors bilaterally but that did improve. Sensation:  She felt pinprick throughout, even though she felt some tingling sensation in both big toes. Vibration was decreased in both toes. Normal position sense. Reflexes were +2 throughout. Toes were downgoing. Gait was normal based. Had some difficulties with tandem gait and mild positive Romberg.

VITAL SIGNS:  Blood pressure 102/72, pulse 74, respirations 18 and temperature 98.6.
HEENT:  Pupils are equal and reactive. There are some surgical changes noted over the left pupil. Sclerae are clear. TMs are clear bilaterally. Oropharynx is well hydrated. No lesions. No erythema.
NECK:  No lymphadenopathy or thyromegaly. Carotids are +2.
HEART:  Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear with no wheezing, rales or rhonchi.
BREASTS: Symmetrical. There is no tenderness. No discrete masses. No nipple discharge. No skin changes.
ABDOMEN: Obese. Positive bowel sounds. Some minimal right upper quadrant tenderness is noted. No rebound or guarding.
GENITOURINARY:  Normal external genitalia. Cervix is without lesions or discharge.
PELVIC:  Exam reveals normal-sized uterus and ovaries. No CMT.
EXTREMITIES:  Without cyanosis, clubbing or edema. Good range of motion. There is no discomfort over the hips bilaterally with palpation.
NEUROLOGIC:  Deep tendon reflexes are +2 and symmetrical. Gait is normal. Cranial nerves II through XII are grossly intact. Motor and sensation are grossly intact.
PSYCHIATRIC:  Normal mood and affect. Alert and oriented x3. Pleasant and cooperative.
SKIN:  No notable lesions or atypical moles.