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Physical Exam Medical Transcription Samples

PHYSICAL EXAMINATION:  GENERAL:  He is quite an ill-appearing Hispanic male, in no acute distress, minimally cooperative with exam, afebrile.  VITAL SIGNS:  Temperature 98.6 degrees, respiratory rate 20 and unlabored, heart rate 78 and regular, and blood pressure 116/70.  HEENT:  The patient has a Shiley tracheostomy in the midline.  We cannot visualize the posterior pharynx.  Anterior pharynx is clear.  Nasopharynx shows a small amount of clear nasal drainage.  Conjunctivae are clear.  He has a copious amount of white tracheal secretions with fairly good spontaneous cough effort.  Tracheostomy cuff is inflated.  CHEST:  He has bilateral coarse rhonchi, particularly over the anterior lung fields, decreased breath sounds at the bases with coarse crackles bilaterally at the bases.  No wheeze.  No stridor.  CARDIOVASCULAR:  He has a regular rate and rhythm, difficult to auscultate over breath sounds.  No murmur or gallop is appreciated.  ABDOMEN:  Slightly distended, soft, no guarding.  Normoactive bowel sounds.  EXTREMITIES:  There is no clubbing, cyanosis, or edema.  NEUROLOGICAL:  He is lethargic, follows a few simple commands, and moves all four extremities.

GENERAL:  The patient was seen in dialysis unit.  He did not appear to be in any distress.
VITAL SIGNS:  His temperature is 98.4 degrees, blood pressure 102/52, respiratory rate 20, and heart rate in the 60s.
SKIN:  No peripheral stigmata of endocarditis.  There are scattered hyperpigmented papular lesions on the trunk.  There is no other rash.  There is no adenopathy.  There is no mucositis.
HEENT:  Grossly intact.  The fundi are not examined.
NECK:  There is a right internal jugular dialysis catheter in place.  The site and the tract are unremarkable.
CHEST:  There is an ICD pocket in the left pectoral area of the chest and that site is also unremarkable.  There is a healed median sternotomy scar.  Sternum is stable.
LUNGS:  Clear.
HEART:  There is no audible murmur, gallops or rubs.
ABDOMEN:  Soft and nontender.  There is hepatosplenomegaly.
EXTREMITIES:  No cyanosis, clubbing or edema.  There are failed fistulas and grafts, two in each arm.  Lower extremities are unremarkable.
NEUROLOGIC:  Examination is nonfocal.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Within normal limits.  EXTREMITIES:  Examining the patient at bedside, vascular status was +1/4 dorsalis pedis, +1/4 posterior tibial, popliteal, 2/4 femoral.  Temperature is increased on the right versus the left.  NEUROLOGICAL:  Muscle power is all diminished in the lower extremity.  SKIN:  Dry, peeling, with multiple scars from multiple previous ulcerations on lower extremity.  Ulceration at the posterior heel, at the insertion of the Achilles tendon, is oblong shape, 1.4 x 1.2 cm down through the subcutaneous tissue and above the Achilles tendon.  There is a necrotic border with a serosanguineous discharge.  Aquacel dressing was in place at the time of examination.  The nails are thick, elongated with subungual and superficial debris, well trimmed at this time.

PHYSICAL EXAMINATION:  GENERAL:  Alert, awake, oriented female in no distress.  VITAL SIGNS:  Blood pressure 160/86.  Heart rate 72.  She was afebrile.  Saturation was 97%.  NECK:  There was no JVD or carotid bruits.  LUNGS:  Equal air entry bilaterally.  HEART:  Normal S1 and S2 with 1-2/6 systolic murmur.  ABDOMEN:  Soft but there was a large ventral hernia.  There was mild tenderness but no guarding.  EXTREMITIES:  Revealed palpable pedal pulsations with 1-2+ edema bilaterally.

PHYSICAL EXAMINATION:  GENERAL:  The patient is a middle-aged lady in no acute distress.  VITAL SIGNS:  Blood pressure 112/72, respiratory rate of 12-14, temperature of 98.4 degrees Fahrenheit, and a heart rate of 88.  HEENT:  Head is normocephalic and atraumatic.  Pupils are round, reacting to light, anicteric sclerae, pale conjunctivae.  Ear, nose, and throat are within normal limits.  NECK:  Supple.  No JVD, no lymphadenopathy, and no thyromegaly.  CHEST:  Moves symmetrically with inspiration and expiration with good air entry, occasional crackles at the bases.  CARDIAC:  S1 and S2 noted.  ABDOMEN:  Soft, tympanic, distended.  Bowel sounds are normoactive.  NEUROLOGICAL:  Neurologically, the patient is alert.  EXTREMITIES:  Without any calf tenderness.

PHYSICAL EXAMINATION:  GENERAL:  The patient is a comfortable-appearing female.  SKIN:  Warm and dry.  HEENT:  Head normocephalic.  Eyes, extraocular movements intact.  Ears are clear.  Nose is clear.  Throat is clear.  NECK:  Supple.  Trachea is midline.  No lymphadenopathy.  CHEST:  Symmetrical.  HEART:  Regular rate and rhythm.  S1 and S2.  No adventitious sound appreciated.  LUNGS:  Clear with equal air entry bilaterally.  No rales.  No rhonchi.  ABDOMEN:  Obese, soft, and nontender.  No masses on palpation.  Positive bowel sounds.  MUSCULOSKELETAL:  Normal range of motion.  EXTREMITIES:  Warm.  Pulses 2+.  No edema appreciated.  NEUROLOGICAL:  Awake and oriented x3.  No focal neurological deficits appreciated.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Stable.  Temperature is 99.6 degrees.  EXTREMITIES:  The patient states he has pain in his lower extremity extending from his knee down into his ankle and foot.  Nails are thick and elongated with subungual and superficial debris, 1 through 5 bilaterally.  NEUROLOGICAL:  Sharp/dull, light touch, proprioception are all diminished.  Muscle power is +3/5, dorsiflexor and plantar flexor, to inversion and eversion.  SKIN:  Peeling and dry throughout the lower extremity extending down into the toes with slight maceration.

PHYSICAL EXAMINATION:  General:  On examination, the patient is a weak, ill-appearing male who looks older than his stated age.  Vital Signs:  His blood pressure is normal.  He is afebrile.  His urine output has been recorded as about 150 mL yesterday for an intake of about 330 mL.  HEENT:  He has a large, irregular ulcer on the left cheek.  There appears to be no obvious signs of infection.  Neck:  He has positive jugular venous distention.  No carotid bruits.  Lungs:  Diminished breath sounds on the right hemithorax.  He has some rales at the left hemithorax.  Cardiac:  A 1/6 systolic murmur.  Abdomen:  Soft.  Extremities:  2+ edema with erythema over the left leg.

PHYSICAL EXAMINATION:  GENERAL:  The patient appears moderately ill.  VITAL SIGNS:  Temperature 102, blood pressure 122/72, heart rate 100, respiratory rate 20, and O2 saturations are 98% on room air.  HEENT:  There is no rash, adenopathy or mucositis.  There is some white particulate matter on the tongue but no evidence of Candida on the buccal mucosa.  The rest of the pharynx is unremarkable.  NECK:  Supple.  No carotid bruits.  No thyroid masses.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm.  There were no murmurs, gallops or rubs.  ABDOMEN:  Soft.  There is a renal transplant in the left iliac fossa.  There is some mild tenderness with palpation only at the upper pole.  The rest of the abdominal examination is unremarkable.  EXTREMITIES:  No cyanosis, clubbing or edema.  There is a fistula in the arm.  The lower extremities are unremarkable.  NEUROLOGIC:  Nonfocal.

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