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Physical Exam Medical Transcription Samples / Examples

GENERAL:  Reveals a well-developed, well-nourished, chronically ill-appearing female in no acute distress.
VITAL SIGNS:  Blood pressure 110/76, pulse 82 and regular, respirations 18 and unlabored, temperature afebrile.
HEENT:  Normocephalic, atraumatic. Conjunctivae pink. Sclerae anicteric. Pupils equal, reactive to light and accommodation. Extraocular movements intact. Ears, nose, throat clear. Mucous membranes, oropharynx well hydrated. The patient is missing several teeth.
NECK:  Supple without adenopathy, thyromegaly, JVD or carotid bruits.
CHEST:  Symmetrical.
LUNGS:  Grossly clear to percussion and auscultation with diminished breath sounds at the bases.
HEART:  Normal sinus rate, S1, S2, soft S4 without thrills, murmurs.
ABDOMEN:  Soft, obese, +3. Bowel sounds present without obvious organomegaly, masses, rebound or guarding. Negative for CVA tenderness.
EXTREMITIES:  Left lower extremity reveals a fifth toe amputation. There is marked edema in the knee distally, including pedal edema. This is approximately 2+. Peripheral pulses of the left lower extremity are markedly diminished. The patient does have calf tenderness to palpation. There is no evidence for cyanosis at this time. Right lower extremity reveals partial amputation of the first three toes on the right. Peripheral pulse is diminished but palpable. Distal pulses are diminished but palpable.
NEUROLOGIC:  Grossly intact. Detailed sensory examination of the lower extremities was not performed. Ambulation and gait not tested.

VITAL SIGNS:  Temperature 97.4, pulse 102, respirations 18, pulse ox 98% on room air.
GENERAL:  Alert and oriented x4, no acute respiratory distress, sitting on the bed comfortably in the presence of her husband.
HEENT:  On the scalp, there is a healed, granulated, erythematic abrasion on the right occiput. There is no active bleeding or open lesion. The crown of her head shows marked silver hyperkeratinized skin with white flecks throughout the hair region. The head is normocephalic. Eyes show EOMI, PERRLA. Funduscopic exam shows no hemorrhages, AV nicking or edema. Red reflex present. Sclerae white. Conjunctivae pink and moist. Nares patent. No exudates. TMs are intact without erythema or exudates as is the throat. Buccal mucosa is moist. The patient is nontender around the face.
NECK:  Supple. No lymphadenopathy. There is presence of yellow violaceous ecchymosis on the postauricular region of the patient’s neck. There is no lymphadenopathy. There is some slight tenderness. The patient does have a scar in the anterior region of her neck consistent with an old ACDF. Clavicles are nontender.
CHEST:  Nontender.
HEART:  Regular rate and rhythm, S1, S2. No murmurs, rubs or gallops.
BACK:  No cervical, thoracic, lumbar, sacral tenderness. No CVA tenderness.
LUNGS:  Clear to auscultation. No wheezes, rales or rhonchi.
ABDOMEN:  Positive bowel sounds, no hepatosplenomegaly or masses.
NEUROLOGIC:  Cranial nerves II through XII are intact. Romberg is normal. Gait is normal. Strength is 5/5, equal, upper and lower extremities with full range of motion active and passively. Alert and oriented to person, place, time and situation. Sensation is intact on all distal extremities. Cerebellar functions are normal. No pronator drift.
PSYCHIATRIC:  The patient has a normal affect and responds appropriately.

VITAL SIGNS:  Blood pressure 132/88, pulse 76, respiratory rate 18, temperature 98.4 degrees, oxygen saturation 100% on room air.
GENERAL:  The patient is able to speak in full sentences.  Not using any accessory muscles of respiration.  Appears to be in no acute distress.
HEENT:  Eyes:  Sclerae anicteric.  There is no conjunctival pallor.  ENT:  Mucous membranes are moist.  No tonsillar enlargement, erythema or exudate.
NECK:  No lymphadenopathy.
RESPIRATORY:  Clear to auscultation bilaterally.
CARDIOVASCULAR:  S1, S2 present.  No murmurs, gallops or rubs.
ABDOMEN:  Soft.  Tender in the left suprapubic and right suprapubic region.  There is no rebound.  There is no guarding.  There is no abdominal distention.  Bowel sounds present in all 4 quadrants.
PELVIC:  Reveals that there is blood in the vaginal vault.  There appears to be a scant amount of mucopurulent discharge in the cervical os.  The patient does display left and right adnexal as well as midline uterine tenderness as well as cervical motion tenderness.
NEUROLOGIC:  Alert and oriented, answering questions appropriately, moving all extremities x4.
PSYCHIATRIC:  The patient's mood is euthymic.  Affect is congruent with mood.

GENERAL:  Alert and oriented x3, pleasant, cooperative gentleman, somewhat thin looking, does not appear to be in acute distress.
VITAL SIGNS:  Blood pressure 115/70 mmHg, heart rate 55-74 (sinus bradycardia-sinus rhythm), respirations 19-21 breaths per minute.  Afebrile.  Pulse ox 98% on 2 liters per minute of oxygen via nasal cannula continuously.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, reactive to light and accommodation.  Extraocular muscles are intact.  Oropharynx clear.  No abnormal deviations.
NECK:  Supple.  No JVD.  No hepatojugular reflux.  No thyromegaly or lymphadenopathy.  No carotid bruits to auscultation.
LUNGS:  Decreased breath sounds bilaterally.  Some scattered expiratory rhonchi bilaterally.
HEART:  Regular rate, bradycardia.  Heart sounds somewhat distant.
ABDOMEN:  Scaphoid in shape.  Bowel sounds are present.  Soft, nontender, nondistended.  No organomegaly.  No costovertebral angle tenderness to percussion.
GENITOURINARY:  Foley catheter is in place.  Signs of gross hematuria.
EXTREMITIES:  No peripheral edema.  Peripheral pulses are present, decreased over both feet.
NEUROLOGIC:  Grossly intact.

VITAL SIGNS:  Blood pressure 136/84, heart rate 118, respiratory rate 18, temperature 97.8 orally, oxygen saturation 99% on room air.
GENERAL:  A visibly upset and distressed woman found sitting on a stretcher, brought in by squad, breathing normally.
HEENT:  Atraumatic.  Pupils are equal, round and reactive to light.
NECK:  Supple and nontender.  No lymphadenopathy.
PULMONARY:  Chest is atraumatic.  Lungs are clear to auscultation bilaterally.
HEART:  Regular rate and rhythm.  No rubs, murmurs or gallops.
ABDOMEN:  Atraumatic.  Soft and nontender.
SKIN:  No rashes.  Warm, pink and dry.
NEUROLOGIC:  Alert and oriented x3.  Nonfocal.
PSYCHIATRIC:  Mood and affect are appropriate to content.
EXTREMITIES:  Upper extremities:  Atraumatic, warm, pink, 2+ radial pulses, sensation intact to light touch, 5+ motor throughout.  Lower extremities:  Left lower extremity is atraumatic, 5+ motor strength throughout, sensation intact to light touch, 2+ dorsalis pedis pulse.  Right lower extremity:  Atraumatic proximal to the foot.  There is a gunshot wound to the plantar aspect of the right foot with two open wounds.  The fourth toe has a subungual hemorrhage present.  All toes have sensation intact to light touch and the patient is able to move all toes; however, limits the movement due to pain.  Capillary refill is less than 2 seconds in all toes.  There is 2+ dorsalis pedis and posterior tibialis pulse present in the right foot.  The patient is able to dorsiflex and plantarflex her foot with 5+ strength, without any pain.  There is no obvious foreign debris in either of the gunshot wounds.

GENERAL:  Reveals a well-developed, well-nourished female who is quite distraught, but is in no acute distress.
HEENT:  Head normocephalic. Normal hair distribution and texture without masses. The ears are normal. Conjunctivae are noninjected. Sclerae not icteric. The pupils are equal, round and reactive to light. Extraocular movements are full without nystagmus. Visual fields are decreased in the right visual field to confrontation. Fundi are unremarkable. The nose is markedly congested with clear mucoid discharge bilaterally. The uvula elevates in the midline. The tongue protrudes in the midline. There is no injection or exudate. The TMJs are normal without crepitation.
NECK:  Supple without masses, adenopathy or thyromegaly. There is no JVD or HJR. Kernig and Brudzinski signs are negative.
CHEST:  Symmetrical. The chest wall is nontender.
BREASTS:  Symmetrical without masses.
HEART:  Regular rhythm. S1, S2 without S3, S4, murmurs, thrills, rubs or ectopy.
LUNGS:  Clear to P&A.
BACK AND SPINE:  There is no CVA tenderness or spinal deformity.
ABDOMEN:  Soft, warm and nontender without palpable organomegaly or masses. Bowel sounds are present. There are no abdominal bruits. There are no inguinal or femoral hernias or inguinal nodes palpable.
EXTERNAL GENITALIA:  Normal female for age.
SKIN:  No edema, masses or rashes.
VASCULAR:  Reveals good pulses in the extremities and carotids without bruits.
NEUROLOGIC:  The patient is quite upset but alert, oriented and responsive. Motor strength is 5/5 on the right, 3-4/5 on the left. No involuntary movements or tremors. Sensation is decreased on the left. Cranial nerves II through XII intact. The tongue protrudes to the right, but this is not new. Cerebellum cannot be tested. Gait is not tested. Romberg cannot be tested. Reflexes are 2+ biceps, triceps, brachioradialis. The right toe is downgoing. The left toe is neutral.

VITAL SIGNS:  Temperature 98.4, pulse 160, respirations 30, 98% on room air, blood pressure 94/52.
HEENT:  Head appears large (95th percentile for age). No tympanic membrane erythema bilaterally. No pharyngeal erythema or exudate. Mucous membranes moist. No nasal discharge or congestion appreciated. No conjunctival erythema or eye discharge.
NECK:  Supple. No lymphadenopathy.
LUNGS:  Good air entry bilaterally. Minimally coarse on expiration. No actual wheezing. No crackles. No retractions. No tachypnea.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Soft. Positive bowel sounds. Nontender.
GENITOURINARY:  Normal male.
SKIN:  Moist. Capillary refill brisk. No rashes appreciated.
NEUROLOGIC:  Alert, appropriate, smiling, laughing, reaches for things. Good muscle tone.

GENERAL:  The patient is a well-developed, well-nourished male, in no distress. The patient is alert and oriented x3. Affect is normal.
VITAL SIGNS:  Blood pressure 142/72, pulse 72 and regular, respirations normal.
HEENT:  Conjunctivae are pink. Sclerae are white. Skin turgor is normal.
NECK:  No JVD. There is transmitted murmur to his carotids bilaterally. Carotid upstrokes are normal. There is no thyromegaly.
LUNGS:  Significant for crackles bilaterally about one-fourth of the way with no wheezing or rhonchi.
CHEST:  Chest expansion symmetrical.
HEART:  A 3/6 systolic murmur at the base of the heart and right upper sternal border consistent with aortic stenosis as well as a 2/4 diastolic murmur consistent with aortic insufficiency. PMI is normal.
ABDOMEN:  Soft, nontender. No hepatosplenomegaly. There is no pulsatile aorta.
EXTREMITIES:  No clubbing, cyanosis or edema. Motor strength is symmetrical.
SPINE:  There is no kyphoscoliosis.