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Physical Exam (PE) Medical Transcription Words Phrases

GENERAL:  This is a pleasant, cooperative, elderly Hispanic female, who is alert, oriented, and in mild distress due to back pain.
VITAL SIGNS:  Her blood pressure is 150/66, pulse is 82, and respirations are 22. She is afebrile at 97.2.
HEENT:  Normocephalic and atraumatic.  She had a nasal cannula in place.
LUNGS:  She has decreased breath sounds at the bases with poor air movement, but she has good air movement at the upper lobes.  There are no wheezes or rales noted.
HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, and nondistended.  Normoactive bowel sounds.
EXTREMITIES:  She has diminished range of motion throughout and can only flex to about 20 degrees from a supine position.  She has peripheral pulses, which are intact and her toes are pink and warm.  She has no clubbing, clonus, or any edema.  Homans sign is negative and she has no palpable cords.

GENERAL:  This is an elderly, thin, frail (XX)-year-old female. She is in no apparent distress. She is alert and oriented x3, is comfortable, sitting on bed. She is extremely hard of hearing.
HEENT:  Sclerae are clear. Conjunctivae pink. Oropharynx is clear. Mucous membranes are dry.
NECK: Supple. No lymphadenopathy.
CHEST:  Clear to auscultation bilaterally, anteriorly.
HEART:  Regular rate and rhythm. Normal S1 and S2. No murmur is appreciated.
ABDOMEN:  Soft, nontender, and nondistended. Bowel sounds are present. There is no hepatosplenomegaly or masses noted. She does have surgical scars. She does have a PEG tube in place, which is intact.
EXTREMITIES:  No clubbing, cyanosis, or edema. Significant muscle wasting.

GENERAL:  On examination, the patient is not responsive to verbal stimuli.
VITAL SIGNS:  Pulse 98, blood pressure 96/54, respiration 22, temperature 98.8 degrees Fahrenheit.
HEENT:  No JVD.  No carotid bruit.  No lymphadenopathy.
NECK:  Supple.  No engorged neck veins.
LUNGS:  Bilaterally clear to auscultation.  Decreased air entry bilaterally at the bases, most likely secondary to decreased effort.
HEART:  Both heart sounds normally audible.  No murmurs.  No thrills.
ABDOMEN:  Soft. Nontender.  Bowel sounds positive.  No organomegaly.  The patient shows diffuse tenderness over the abdomen.  However, abdomen is soft and there is no guarding or rigidity.
EXTREMITIES:  No edema or cyanosis.

VITAL SIGNS:  Temperature 96.4, pulse 58, respirations 20, blood pressure 168/84, height 5 feet 4 inches, weight 190 pounds.
GENERAL APPEARANCE:  Well-developed, well-nourished, overweight woman, in no acute distress. Her affect was normal.
HEENT:  NC/AT. Pupils equally round and reactive to light and accommodation.
NECK:  Without bruits.
LUNGS:  Clear.
HEART:  Bradycardia with a normal rhythm and without murmur.
ABDOMEN:  Obese. Bowel sounds positive. Soft, nontender, and nondistended.
EXTREMITIES:  No clubbing, cyanosis or edema. No calf erythema, warmth or tenderness. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout, except her left wrist was painful with all movements. The left wrist was tender to palpation. There was some swelling at the left wrist.

VITAL SIGNS:  Temperature 98.4, blood pressure 128/62, pulse 68, respiratory rate 22, 94% pulse oximetry reading.
GENERAL:  Alert, in no distress. The patient is weak overall.
EYES:  Anicteric sclerae, pale conjunctivae.
HEENT:  Moist mucosa. No oropharyngeal lesion noted.
NECK:  Supple in appearance. No thyromegaly appreciated.
LYMPH:  No adenopathy peripherally.
CHEST:  Symmetrical movement. Decreased breath sounds. Poor inspiratory effort. Bibasilar crackles.
HEART:  S1, S2 present. Distant heart sounds noted.
ABDOMEN:  Soft, obese, and nontender. No organomegaly appreciated.
EXTREMITIES:  No edema or cyanosis.
SKIN:  Mottled. No new ecchymosis noted. No petechiae present.
NEUROLOGIC:  Alert and oriented. He has appropriate response.
MUSCULOSKELETAL:  He is able to move his extremities.

GENERAL:  Well-developed, well-nourished Hispanic female, in no acute distress.
VITAL SIGNS:  Temperature 98.4, pulse rate 80, respiratory rate 18, blood pressure 142/64.
HEENT:  No evidence of trauma. PERRLA. Disks sharp bilaterally. Bilateral arcus senilis noted. TMs clear. Throat clear.
NECK:  Supple, no bruits, no JVD, no HJR, no thyromegaly.
CHEST:  Lungs clear bilaterally.
CARDIAC:  Regular rate and rhythm, no S3, murmur or JVD.
ABDOMEN:  Soft, nontender, obese. No organomegaly, normal bowel sounds.
EXTREMITIES:  No clubbing, cyanosis or edema.
NEUROLOGIC:  Awake, answering only a few questions appropriately, but is moving all four extremities with power of 5/5 in all four extremities.

GENERAL:  She is awake, in no acute distress. Afebrile.
VITAL SIGNS:  Temperature 97.6, pulse 64, respirations 20, blood pressure 108/48. Height 156 cm. Weight 66 kg.
HEENT:  Eyes:  No icterus. No petechiae. Oropharynx is clear. On exam of her ears, the right auricle has a small erythematous and scaly lesion of about 0.6 mm without drainage. The right ear canal has plaques and unable to visualize tympanic membrane. The right mastoid without erythema, no fluctuance, no tenderness. The left auricle is without lesions. The left ear canal is clean, no erythema. The tympanic membrane is normal. Left mastoid without erythema, fluctuance or tenderness.
NECK:  Supple. No lymphadenopathy.
CHEST:  Decreased air entry at bases. No use of accessory muscles.
HEART:  S1, S2 regular. No murmurs.
ABDOMEN:  Soft, nontender, nondistended. Bowel sounds present.
SKIN:  Without rashes.
MUSCULOSKELETAL:  No joint swelling or erythema.
EXTREMITIES:  No erythema or drainage. No swelling.

VITAL SIGNS:  Blood pressure 154/94, pulse 56, respirations 18, temperature 98.2, pulse oximetry 98% on room air.
HEENT:  Head is normocephalic and atraumatic. TMs are clear. Pupils are equal and reactive to light. The patient has an obvious small lesion in his left eye just lateral to his pupil. On eye exam, the patient does not seem to have any foreign body. His cornea is very injected and the lesion is small, approximately 2-3 mm in diameter.
NECK:  No lymphadenopathy. No thyromegaly.
HEART:  Regular rate and rhythm.
ABDOMEN:  Soft, nondistended, nontender.

GENERAL:  The patient is a well-developed, well-nourished female.
VITAL SIGNS:  Temperature 97.6, pulse 84, respirations 22, blood pressure 188/92 decreased to 148/80, pulse oximetry 96% on room air which is normal, weight 72 kg.
HEENT:  Normocephalic, atraumatic. Extraocular movements intact. Pupils equal, round and reactive to light. Negative for hemotympanum, Battle sign, raccoon eyes. Facial buttresses are stable. Occlusion intact.
NECK:  C-spine nontender, negative for crepitus. Trachea midline.
HEART:  Regular rate and rhythm without murmur.
LUNGS:  Clear to auscultation and percussion. Breath sounds equal. Negative for wheezes, rhonchi, crackles or stridor.
ABDOMEN:  Soft, nontender. Positive bowel sounds. Negative for palpable masses, hepatosplenomegaly, costovertebral angle tenderness, peritoneal signs or guarding.
EXTREMITIES:  Atraumatic. Negative cyanosis, clubbing or edema. Radial artery and dorsalis pedis pulses 3+ to palpation, bilateral upper and lower extremities.

VITAL SIGNS:  Blood pressure 114/74, pulse 76, respiratory rate 20, temperature 98.6, pulse oximetry is 96% on room air.
GENERAL:  The patient is alert and oriented x 3, in no acute distress.
HEENT:  Pupils are equal, round and reactive to light. Extraocular movements are intact. Oropharynx is clear. Mucous membranes are moist. No hemotympanum. No Battle sign. No raccoon eye. No otorrhea. No rhinorrhea. No nasal septal hematoma. Orbits, mid face, mandible and dentition are atraumatic, but the patient does have tenderness over the nasal bones and nasal deviation towards the right.
NECK:  Supple, nontender to palpation, no lymphadenopathy, no masses, no JVD, no carotid bruits, no meningismus. C-spine is nontender to palpation. Trachea is in the midline. No subcutaneous crepitus. No hematoma overlying the great vessels.
CHEST:  Clear to auscultation bilaterally. No evidence of trauma.
CARDIAC:  Regular rate and rhythm. No murmurs, rubs, or gallops.
ABDOMEN:  Bowel sounds are present. The belly is soft, nontender, nondistended. No masses, no hernias, no rebound, no guarding.
BACK:  No CVAT. T and LS spine nontender to palpation.
EXTREMITIES:  Distal pulses 2+ bilaterally. No clubbing, cyanosis or edema. Pelvis is stable to rock. Negative log roll bilaterally. The patient has a few scrapes over his knuckles on the left hand, but otherwise, his left hand is atraumatic and nontender. He has tenderness and edema overlying his fourth metacarpal. He has full range of motion of the wrist without pain or tenderness. Right radial pulse is 2+. Right radial, ulnar and median nerve motor and sensory functions are intact. FDS, FDP and extensor tendon flexion are intact. There is no scissoring of the pinkie finger, has a normal cascade with no evidence of rotational deviation.
SKIN:  No rash, no petechiae, no purpura, no jaundice.
PSYCH:  Normal mood, normal affect.
NEUROLOGIC:  Alert and oriented x 3, normal mental status, cranial nerves II through XII intact, strength 5/5 bilaterally throughout. Station and gait within normal limits.

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