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Physical Exam Medical Transcription Dictation Examples

PHYSICAL EXAMINATION:  The patient is a very pleasant young girl. Height is 61.6 inches, 21st percentile. Weight is 117 pounds, 66th percentile. Body mass index is 21.7, 70th percentile. Blood pressure is 104/64. HEENT:  Both tympanic membranes are clear. Both conjunctivae are clear. Nose is clear. Mouth is clear. There is no neck mass. Lungs:  Good air entry and clear breath sounds. Heart:  Normal first and second heart sounds. Regular rhythm. No murmurs. Abdomen:  Flat, soft, no mass, no tenderness. Breasts:  Tanner IV. Female Genitalia: Tanner IV. Skin: Clear. Neurologic examination is normal. Extremities: Femoral pulses are equally palpable. No deformity noted. Full range of motion of all four extremities.

PHYSICAL EXAMINATION:  Blood pressure was 122/72, pulse 84, and respiratory rate was 20. The patient seemed somewhat depressed but in no acute distress. Neck was supple, no bruits. Heart had regular rhythm. Extremities had no edema noted. On neurologic examination, the patient was alert and oriented x3. Normal attention and language. No neglect or apraxia was noted. Cranial nerve examination:  Pupils were equal and reactive to light. Full visual fields to confrontation. No visual extinction to double simultaneous stimulation was noted. Disks were sharp bilaterally. Extraocular movements were intact with no nystagmus. The patient's strength was normal. Normal hearing bilaterally. Palate elevated well and symmetrically. Normal shoulder shrugs. Tongue was midline. Motor strength was 5/5 throughout without any pronator drift. Normal muscle tone. No abnormal movements were noted. Intact pinprick throughout. No sensory extinction to double simultaneous stimulation was noted. No significant finger-to-nose or heel-to-shin test. Gait was normal based with intact tandem gait.

PHYSICAL EXAMINATION:  Height 5 feet 7 inches, weighs 164 pounds. Healthy-appearing male, in no acute distress. He is walking with a slight antalgic gait. He has significant pain while walking on his toes. He can walk on his heels. He can walk on the outer border of his foot. Good sagittal motion, good hindfoot motion, 5/5 strength in dorsiflexion, plantarflexion, inversion, eversion. Ankle and hindfoot are stable to stress examination. Sensation is intact in all four dermatomes. Palpable pulse on the dorsum of his foot. Skin is supple. No abnormal callus formation. Tender to palpation throughout his midfoot, but essentially at the second and third metatarsals. He is also having significant pain at his fourth proximal metatarsal shaft. He has significant hallux valgus with a widened intermetatarsal angle hypermobility. No tenderness at his first MTP joint. No hammering of toes.

VITAL SIGNS:  Blood pressure is 152/78 with a heart rate of 82. Weight is 204 pounds. Respirations are 12. Temperature is 98.4. Pain score is 10.
GENERAL:  The patient is alert and oriented x3. Appears to be in some distress while climbing up to the examination table.
HEENT:  Pupils are equal and reactive to light bilaterally. Extraocular muscles are intact. The oropharynx is within normal limits. Nasal turbinates are also within normal limits. Uvula is midline. There is no JVD noted. Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
HEART:  S1, S2, regular rate and rhythm. No murmurs, no rubs or gallops.
ABDOMEN:  Bowel sounds are positive in all 4 quadrants.
SKIN:  Intact. No rashes. No erythema. Multiple seborrheic keratoses were noted.
EXTREMITIES:  The patient has 5/5 strength in all extremities. The patient complains of pain to palpation in the glenohumeral joint on the left. No pain on the right. The patient also complains of joint pain over the medial aspect of the elbow. The patient has full range of motion of all 4 extremities. Sensation is intact in all 4 extremities. Reflexes are +2, biceps, triceps, patellar.

PHYSICAL EXAMINATION:  Blood pressure 124/84, heart rate 58, weight 220 pounds, temperature 97.4, oxygen saturation 98% on room air. Has 7/10 pain all over, particularly at the knees, back, and left foot. He has no synovitis in the wrists, PIPs or MCPs. He has some Heberden's and Bouchard's nodes. Knees are cool without effusions. He has crepitus. No clubbing, cyanosis, or edema. Do not detect any dactylitis or synovitis in the feet. Lungs are clear. Heart has regular rate and rhythm, S1, S2. Negative straight leg. Toes are downgoing.

PHYSICAL EXAMINATION: The patient is 5 feet 7 inches tall. He weighs 170 pounds. He is pleasant, cooperative, and in no acute distress. No pain to palpation in his left shoulder. He has full range of motion with pain at the end ranges. Positive Hawkins maneuver, mild tenderness with cross-body adduction testing. He has weakness with external rotation and mild weakness with supraspinatus testing. Neurovascularly intact distally.

VITAL SIGNS:  The patient is afebrile with a pulse of 84, blood pressure 158/88, respiratory rate of 22, and O2 saturation of 92%.
GENERAL:  This is a well-developed, well-nourished woman who is in no apparent distress. She is mildly tachypneic but is able to speak full sentences without difficulty.
HEENT:  Anicteric sclerae. There is no sinus tenderness. Does have dentures. There is no oral thrush.
NECK:  No lymphadenopathy or JVD.
LUNGS:  There is no stridor.  Lung exam is remarkable for intermittent inspiratory squeak over the left upper lobe anteriorly. There is also soft end expiratory wheeze over the right upper lobe posteriorly. There is no accessory muscle use.
HEART:  Regular rate and rhythm without any murmurs, gallops, or rubs.
ABDOMEN:  No distention. There is normal bowel sounds. Abdomen is soft and nontender.
EXTREMITIES:  No cyanosis, clubbing, or edema.
NEUROLOGICAL:  Grossly nonfocal on strength testing. However, this was limited because of her overall condition.

PHYSICAL EXAMINATION:  Height is 5 feet 4 inches. Weight is 124 pounds. The patient presents in no acute distress but is notably uncomfortable in the right shoulder. Examination of the right shoulder revealed forward flexion, forward extension 175; external rotation 60 degrees, internal rotation to T5. The patient had 5/5 strength. She was neurovascularly intact during gross exam. Positive O’Brien test. Positive dynamic labral shear. Negative apprehension test, negative Jobe relocation test, negative load and shift, negative lift-off, positive Neer test, positive cross-body adduction but pain was not isolated at the AC joint, positive Speeds test, no AC joint tenderness, positive biceps tenderness proximally. The patient had no obvious deformities, ecchymosis, or erythema. Skin was intact.

PHYSICAL EXAMINATION:  The patient is a somewhat anxious (XX)-year-old male in no acute distress. He is oriented x3 and cooperative. Blood pressure is 144/90. Heart rate is 94 with occasional extrasystoles. Oxygen saturation is 99%. Eyes show round, reactive pupils. Sclerae are anicteric. Chest was clear to auscultation bilaterally. Heart is in regular rhythm with a grade 3/6 crescendo-decrescendo systolic ejection murmur over the sternal border and a grade 2/6 holosystolic murmur of mitral regurgitation heard at the apex and radiating out toward the axilla. There is also a diastolic murmur, grade 2/6, heard over the precordium and out to the left ventricular apex. The abdomen is soft without organomegaly or masses. Bowel sounds are normal. The pulses show symmetric radial and brachial pulses without a water hammer quality. Pedal pulses are 3/4 bilaterally. There is no ankle edema.

PHYSICAL EXAMINATION:  On exam, the patient is not in acute distress. She has Heberden's and Bouchard's nodes and squaring at the base of her thumb bilaterally without any significant synovitis. She has a positive Finkelstein sign on the right hand consistent with de Quervain's tenosynovitis and is very tender at the abductor tendons along the thumb. Knees are cool without effusions. She is tender at the right pes anserine bursa on palpation. She is tender at the bilateral greater trochanters on palpation. She has a little bit of swelling at the lateral malleolus and right ankle, nontender over any of the MTP heads, and no swelling or acute podagra. Moist mucous membranes. No overt alopecia. Lungs were clear. Abdomen is soft and nontender. Regular rate and rhythm, 2/6 systolic ejection murmur at the left upper sternal border. No clubbing, cyanosis, or edema. Alert and oriented x3.

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