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Physical Exam Template Format Medical Transcription Examples

PHYSICAL EXAMINATION:  On admission to the ED today, his temperature was 98.4, blood pressure was 116/76, pulse was 120, respiratory rate was 18, O2 saturation was 98% on room air. The patient is a (XX)-year-old well-developed, well-nourished male. He is clearly uncomfortable but in no acute cardiopulmonary distress. He is awake, alert and oriented x3. He is pleasant and cooperative with the exam. He has been drinking a little bit of wine this night though he is not clinically intoxicated. His head is normocephalic and atraumatic. Pupils are equal, round and reactive to light and accommodation. Extraocular muscles are intact. The patient has some minimal photophobia to the right eye but no consensual photophobia. Initially, checked the visual acuity and it was 20/25 in the left eye and 20/100 in the affected right eye. However, at this point, the patient had a lot of tearing to the eye and was unable to really open the eye very well. Here in the ED, his globe is intact. Tetracaine was used to numb the eye with good anesthetic effect obtained and the patient was able to open the eye and feels much better following this. Following tetracaine administration, his visual acuity was 20/50 in the right eye and 20/20 in the left eye. With fluorescein staining, the patient was noted to have a 3 to 4 mm corneal abrasion to the center of his vision running along the vertical axis. On slit-lamp examination, however, the globe is intact. There is no cell or flare and no other abnormalities other than this corneal abrasion. There is no evidence for retained foreign body and his upper and lower lids were everted and swabbed with a cotton swab. The rest of his exam is unremarkable.

VITAL SIGNS:  Temperature 97.8, pulse 66, respirations 21, BP 130/78, pulse oximetry 98% on room air.
GENERAL:  The patient is a well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old male. The patient is alert and oriented x3. His Glasgow coma scale is 15.
HEENT:  Normocephalic, atraumatic facies. Ears, eyes, nose, throat all within normal limits. Mucous membranes are moist and pink. Sclerae are nonicteric. Pupils are equal, round, reactive to light and accommodation. Funduscopic examination reveals no evidence of obvious floaters. Cup-to-disk ratio appears to be grossly normal and there is no evidence of AV nicking or other exudate. The patient exhibits equal ocular movements as well. Visual fields were tested which revealed no evidence of deficit.
NECK:  Supple, nontender. No meningismus. Trachea midline.
LYMPHATICS:  The patient exhibits no lymphadenopathy.
CHEST:  Reveals equal bilateral breath sounds. Clear to auscultation with normal chest wall excursion.
CARDIOVASCULAR:  Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN:  Benign.
EXTREMITIES:  Examination reveals full range of motion of all extremities without deficit. The patient exhibits strong distal pulses, brisk capillary refill.
NEUROLOGIC:  Reveals no gross motor or sensory deficits. The patient is alert and cooperative. Cranial nerves II through XII are grossly intact. Cerebellar function intact as well. Motor strength 5/5 in all extremities. Deep tendon reflexes 2+ and equal in all extremities and he exhibits intact distal sensation in all extremities as well.
SKIN:  No rash or lesions. Skin is warm and dry to touch with normal tone and turgor.

VITAL SIGNS:  Blood pressure 170/86, heart rate 96, respirations 18, temperature 98.4 and O2 sat is 100%.
GENERAL:  The patient is in no acute distress.
HEENT:  Normocephalic and atraumatic. Oropharynx is pink. Mucous membranes are moist. TMs are clear. Ocular exam:  Lids, lashes and nasolacrimal ducts are normal. There is no conjunctival injection. There are no corneal epithelial defects. The cornea is not cloudy; it is very opaque. There is no evidence of any cell or flare in the anterior chamber. Funduscopic exam is limited by the fact that she is not dilated. I do not appreciate disk margins well. Extraocular motion is full. The pupil is 4 mm, reactive to 2 mm. There is no APD. Visual acuity in the affected eye is at this point 20/200. She is able to read the E on the eye chart. The left is 20/30. These are both with correction.
NECK:  No stridor, no JVD, no bruit, no thyromegaly and no nuchal rigidity.
CHEST:  Clear to auscultation and percussion.
HEART:  Regular rate and rhythm.
ABDOMEN:  Bowel sounds are positive. Nontender and nondistended. No hepatosplenomegaly.
MUSCULOSKELETAL:  Joints have full range of motion. There is no clubbing, cyanosis or edema.
LYMPHATIC:  No axillary or cervical lymphadenopathy.
SKIN:  No petechial or purpuric rashes.
PSYCHIATRIC:  The patient is alert and oriented.
NEUROLOGIC:  Strength is 5/5.

PHYSICAL EXAMINATION:  On physical examination, the patient has exquisite pain with internal rotation of the right hip in about 5 degrees of internal rotation. External rotation is about 20 degrees and has pronounced pain greater than with anterior impingement.  The patient has a positive posterior impingement sign.  Left hip, the patient has about 5 degrees of internal rotation and 25 to 30 degrees of external rotation, but this is not painful.  The patient has 5/5 iliopsoas, quad and hamstring strength.  The patient has 5/5 EHL, TA, gastrocsoleus and peroneal strength bilaterally. The patient has 2+ pulses.  Bilateral sensation is intact to light touch of both lower extremities.  On her right side, she has about 15 cm distance between the table and her knee during a fabere/Patrick test, which is positive as well and this is significantly different than the left side where she can get down to about 5 inches.  The patient has no pain with log roll with either side, and when she lies flat with her leg externally rotated, she does note an ache in the posterior part of her buttocks, which may or may not correlate with this posterior impingement sign.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Per nursing record with the exception of blood pressure of 142/86 and a pulse of 102.  GENERAL:  The patient appears well hydrated and well nourished. Alert and oriented x4, cooperative and in no apparent distress.  HEENT:  The patient's extraocular movements are intact. Pupils are equal, round and reactive to light and accommodation, 3-2 mm bilaterally. The patient's nasopharynx shows no visible deformity. There is some dried blood in the right naris and a small amount of tacky blood in the left naris. There is no visible septal hematoma. There is no tenderness to palpation of the nose. The patient's oronasopharynx shows pink moist mucosa. It is not erythematous, no exudate appreciated. There is no blood seen in the posterior oropharynx. NECK:  Supple. There is no posterior midline tenderness. There is no JVD or carotid bruits appreciated. HEART:  Regular rate and rhythm present, S1 and S2 present without any extra sounds or murmurs appreciated. LUNGS:  All fields are clear to auscultation bilaterally with good air movement in all fields bilaterally. There is resonance to percussion in all fields. THORAX:  There is no midline or costovertebral angle tenderness. There is no axillary lymphadenopathy present. ABDOMEN:  Soft and nondistended with positive bowel sounds in all 4 quadrants. The abdomen is nontender without guarding, rebound or organomegaly present. EXTREMITIES:  There is 5+ strength, intact distal pulses and sensation intact to light touch in all 4 limbs. NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally. The patient responds appropriately to questioning with normal thought content and process. There are no focal neurologic deficits. The patient is able to walk with a normal gait. PSYCHIATRIC:  Normal mood and affect.

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