Physical Exam Medical Transcription Samples

PHYSICAL EXAMINATION:  General:  In no distress. Vital Signs:  Blood pressure elevated today at 164/58, pulse 72 and regular, height 5 feet 8 inches, weight 150. HEENT:  Negative. Mouth clear. Neck:  Supple. No lymphadenopathy or thyromegaly. Carotids are 2+. No bruits. Chest:  Clear. Cardiac:  S1 and S2. S4. A 2/6 systolic murmur with a faint click and a faint AI murmur of 1/6. Abdomen:  Unremarkable. Good bowel sounds. No organomegaly. Genitalia:  Deferred. Rectal:  Deferred. Extremities:  Osteopenia of both knees with some crepitus. Decreased range of motion of the left hip, but good enough range of motion for walking. Dupuytren contracture bilaterally, more on the right than the left. No edema. Neurologic exam is grossly intact. Romberg is negative. Slight tremor at rest.

OBJECTIVE:  On exam, blood pressure is 132/80. Temperature is 98.8. Exam of his hand reveals a rash consistent with dermatitis. There are no open areas. No drainage but mild redness and some scaling of the skin. There is no induration or no fluctuance. Exam of his back reveals full range of motion of his back. He is able to go up on his tippy toes and take a few steps. Reflexes are 2+ and equal. Strength of 5/5. Straight leg raise, sitting and lying, is negative. His sensation to light touch is intact. He has no tenderness to palpation of his back. His knee has full range of motion as do his hips and no calf tenderness.

PHYSICAL EXAMINATION:  Weight 146, BP 102/72, heart rate 86, height 5 feet 6 inches. HEENT:  No adenopathy. Anicteric sclerae. Clear oropharynx. No frontal or maxillary sinus tenderness. Neck:  Supple. Lungs:  CTAB. Heart:  RRR. No murmurs. Abdomen:  Soft and nontender. Positive bowel sounds. Extremities:  No edema. Neurologic: Intact upper and lower extremity motor, sensation and DTRs. Gait unremarkable. Skin:  No atypical lesions. GU:  Intact secondary sexual characteristics. No evidence of inguinal adenopathy or testicular pain, adenopathy, bulge or testicular mass.

PHYSICAL EXAMINATION:  Vital Signs:  He is 6 feet 3 inches tall. Weight is 180 pounds. Blood pressure 112/62. Pulse 60 and regular. HEENT:  Pupils are reactive to light. Sclerae without icterus. Neck:  Supple. Lungs:  Clear. Spine:  No focal bony tenderness. Heart:  Regular rhythm, late systolic click. No murmur. Carotids have no bruits. Abdomen:  Soft without focal mass or tenderness. Extremities:  Without edema, cyanosis or clubbing. He has good pedal pulses. Neurologic:  Nonfocal. Skin:  He has a flesh-colored mole on the left anterior chest and some skin tags in the axillary line. He also has a rash in the right scrotal area consistent with eczema. He also had a mild sore throat and some hyperemia in the left tonsil for which rapid strep is being done today and will notified before he leaves the office.

PHYSICAL EXAMINATION:  On exam, pleasant female in no distress. Elbow, hand and wrist motion are full and flexion of her left wrist specifically is to 60, extension is to 70, pronation 80, supination 80. With rotation, especially against resistance, she has ulnar-sided left wrist pain. There is no instability at the DRUJ. She has no significant pain with ulnar deviation. She has mild tenderness at the radiocarpal joint dorsally but no evidence of carpal instability. She can make a full fist, fully extend her digits. Motor and sensation are intact. She has minimal tenderness today along the left medial elbow.

PHYSICAL EXAMINATION:  The patient is a very pleasant female in no distress. She is 5 feet 8 inches, weighs 184 pounds. Cervical neck motion without pain. Elbow motion without pain and negative Tinel’s over the cubital tunnel or pronator. Markedly positive Tinel’s over both carpal canals. Both carpal tunnel compression test and Phalen’s maneuver 5 seconds on the right and 15 seconds on the left. There is no thenar atrophy. Motor and sensation are grossly intact, except for the median nerves on the right. Again, no atrophy noted. No masses, warmth or erythema. There is brisk capillary refill.

VITAL SIGNS:  Blood pressure 126/72, pulse rate 60 beats per minute and regular, respirations 18, temperature afebrile.
HEENT:  Head: Normocephalic. Eyes: No bitemporal visual field cut. Ears: Hearing is grossly normal. Nose and Throat: No mucosal lesions are present.
NECK:  No carotid bruits. No cervical lymphadenopathy. Trachea is midline. Thyroid not enlarged.
CHEST:  Lungs are clear to percussion and auscultation.
HEART:  Has a regular rate. No murmurs. No signs of congestive failure present.
ABDOMEN:  The pulsatile aortic mass does appear to be approximately 7.6 cm in diameter. There is no tenderness of the aneurysm, no flank ecchymosis.
EXTREMITIES:  Femoral pulses are normally felt. There is no cutaneous embolization to the legs. No cyanosis or ulceration.
NEUROLOGIC:  No appreciable tremor. He seems to initiate speech fairly readily and I do not see signs of slowing or parkinsonian rigidity.

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PHYSICAL EXAMINATION:  The patient appears to be unarousable. On detailed exam, deep sternal rub does seem to provoke slow eye opening. The patient has not been opening her eyes much otherwise. Cranial nerve testing demonstrates minimal pupil reactivity, which is symmetrical. Corneal reflex is obtained. Oculocephalic maneuver is intact. The patient is noted to take very quick breaths, hyperventilating. Motor examination demonstrates no spontaneous movements. There is no localization to pain or withdrawal to painful stimuli in the extremities noted. Reflexes are hypoactive.

PHYSICAL EXAMINATION:  The patient is a pleasant female in no acute distress. HEENT:  Pupils reactive. TMs clear. Pharynx without any exudate or swelling. Neck:  Without any thyromegaly or masses. CVS: S1, S2, regular. No gallop, no murmur, no carotid bruit; 2+ DP, no CCE. Lungs:  Clear to auscultation. No wheezing. Easy respiratory effort. Bilateral breasts are nontender. No masses on palpation. No nipple drainage. Abdomen:  Soft, nontender. Bowel sounds are present. GU exam not done per the patient’s request. Neurologically alert and oriented. Moves all 4 extremities. Light touch is equal. Mood is fine. Affect is appropriate.

PHYSICAL EXAMINATION:  The patient is a healthy-appearing male in no acute distress. He is walking with a slight antalgic gait. No swelling today. Has good sagittal motion. Essentially no hindfoot motion, inversion, eversion, though he does have some passive subtalar motion that does not appear to cause pain. He has some tenderness to palpation in his sinus tarsi. Sensation is intact in all 4 dermatomes. Palpable pulse on the dorsum of his foot. His skin is supple. No abnormal callus formation. Drawer sign is negative today.

PHYSICAL EXAMINATION:  Blood pressure 142/80, pulse 66, respirations 18. Generally, the patient appears well and in no acute distress. Heart has regular rate and rhythm. Lungs are clear to auscultation bilaterally. On neurological exam, the patient is awake, alert and oriented x3 with intact recent and remote memory. Pupils are equal, round and reactive to light. Extraocular movements are intact. Visual fields are full. Face is symmetric. Tongue and palate move normally. On motor exam, normal bulk and tone. No pronators drift. His fine finger movements are slightly slowed on the left. Sensory exam is intact to light touch without extinction. Coordination intact and gait was well balanced, narrow based and symmetric.

PHYSICAL EXAMINATION:  Blood pressure 142/90 with pulse of 60 and regular, respiratory rate 18. She is pleasant and cooperative sitting in a wheelchair. She is conversant and appropriate with normal affect and is well groomed. She has no dysarthria, aphasia or right-left confusion or finger agnosia. Calculations are intact. Her recall is 2 out of 3 without prompting and no improvement with prompting. She knows the year, month and day of the week and she knows the name of the President of the United States. There were no carotid or orbital bruits and radial pulses were symmetric. Cardiac examination was unremarkable. Cranial nerve examination reveals normal fundi, normal visual fields. Pupils are symmetric and reactive. Extraocular muscle movements are full without nystagmus. There is no facial weakness and tongue is midline. Palate elevates symmetrically bilaterally. Hearing to bedside testing is normal. Shoulder shrug is normal. Motor examination revealed some variable weakness noted on the left side, primarily in the left arm and the wrist, and some weakness may be noted also in the left hip flexor. She is able get up from a chair without assistance, although swings herself forward and uses a cane to ambulate. With a cane, her ambulation is reasonable and steady. She has decreased vibration sense in the distal lower extremities. Reflexes are slightly brisker on the left, especially triceps and left knee reflex while the rest reflexes are 1+ to trace and toes are mute.

PHYSICAL EXAMINATION:  Her height is 62 inches, 17th percentile. Weight is 130 pounds, 59th percentile, down 3 pounds. Blood pressure is 110/70. BMI is 23.82, 75th percentile, which is down from 24.8 last year. She is a well-nourished, well-developed female in no acute distress. Skin is clear. No acne. Normocephalic, atraumatic. TMs are normal bilaterally. Pupils are equal and reactive to light. Extraocular muscles are intact. Red reflex bilaterally. Throat negative. Neck: Negative. Lungs: Clear to auscultation. Heart: Regular rate and rhythm. Breasts: Tanner V. No masses. Abdomen: Soft, positive bowel sounds. No hepatosplenomegaly. Pelvic exam was deferred. Extremities: Within normal. Neurologic: She is a very pleasant female. DTRs are equal. Cranial nerves are intact. She is nonfocal. She is nondepressed. She seems in quite good spirits.

GENERAL:  The patient is a pleasant, well-appearing female in no distress. She has some short-term memory issues.
VITAL SIGNS:  Her blood pressure is 170/82, checked twice. Weight is 140 pounds.
HEENT:  Eyes anicteric.
NECK:  There are bilateral neck bruits, left greater than right, some of which may be transmitted from a more proximal source.
CHEST:  Reveals bibasilar coarse crackles.
CARDIAC:  Regular rate and rhythm at 72. Normal S1, S2 is well heard. No S3. No S4. There is a loud 3/6 crescendo-decrescendo murmur heard across the precordium. It is at least mid if not late peaking. Carotid upstroke is 1+ to 2+. No carotid delay.
ABDOMEN:  Soft, nontender, nondistended.
EXTREMITIES:  No edema. Pedal pulses are not palpable. Reflexes are 2+ at the knees bilaterally, absent at the ankles. Plantar response is flexor bilaterally. Motor strength is 5/5 to the lower extremities both proximally and distally bilaterally.

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