Physical Exam Template Examples

Physical Exam Section Transcription Examples for Reference by MTs:

PHYSICAL EXAMINATION:  Blood pressure 130/84, pulse 88, weight 242 pounds, temperature 98, O2 saturation 98% on room air, and pain 1/10 in the legs. The patient is in acute distress, alert and oriented x3. Sclerae anicteric. No conjunctival irritation. Oral mucosa moist. No oral ulcers. Neck is supple. No lymphadenopathy. No thyromegaly. Lungs are clear to auscultation bilaterally. The patient had full range of motion of all of his joints with no synovitis. Strength is 5/5 globally. He denied having any tenderness over his quadriceps tendon. There was no tenderness over the joint lines of his legs. He did have some mild effusion on the medial aspect of his left knee, which the patient tells me is chronic since his ACL surgery. He had slight laxity of medial and lateral collateral ligaments of the knees, right worse than left, but with minimal laxity. Lachman test was negative. He had no tenderness on palpation of the calves. There does not seem to be any swelling in the calf area.

PHYSICAL EXAMINATION:  The patient did not want a full body exam. We did an exam from the waist up. The patient has notable seborrheic keratoses all over his back; some are on the front and on the shoulders. In addition to this, the patient has a couple of telangiectasias on his nose and the left side of his mouth. The patient has a lesion under his right eye, on his right cheek; it is small. When he first came in, it was relatively flesh-colored with a large black scab over it. Removing the scab, the area continued to bleed somewhat. Under a small magnifying glass, one can see small gray punctate lesions around the lesion.

PHYSICAL EXAMINATION:  Reveals a very thin woman, frail appearing, lying in the emergency department trauma bay with a C-collar in place. HEENT: The patient has periorbital ecchymosis, right greater than left, and nasal deformity with associated swelling. Nasal bones are deviated to the left. There is no septal hematoma. There is very small superficial skin tear at the junction of the eyelid and the nasal side wall below the medial canthus on the right. Right periorbital region is edematous and ecchymotic. She has full extraocular muscles with no diplopia. Bony prominences of the face are stable and nontender to palpation with the exception of the nose. Mid face is stable. Dentition is intact. Occlusion is baseline per the patient. Sensation and muscle movement are symmetric and intact bilaterally. Trachea is midline.

PHYSICAL EXAMINATION:  This is a very nice (XX)-year-old male. He was examined in the presence of his father. On the face, he has no acneiform lesions present, but he does have some hyperpigmented macules where his acne is starting to resolve. On the central chest, he has a 2.5 mm firm, white, subcutaneous mobile acne nodule that has been present since the beginning of Accutane therapy. He states that it is getting a little bit smaller. On the left dorsal foot, he has a 2 cm erythematous, scaly plaque. KOH was negative. The patient does have dry skin and calluses on the bottoms of his feet.

PHYSICAL EXAMINATION:  Vital Signs: Blood pressure 142/76, pulse 112, weight 152 pounds, temperature 98.4, and O2 saturation 98% on room air. General Appearance: Well-appearing, pleasant female in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Left-sided immature cataract. External ears: Tympanic membranes appear normal. No oropharyngeal redness or lesions. Neck: Supple. No JVD. No masses. Heart: Regular S1, S2 present. No murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. No rhonchi, rubs or wheezing. Abdomen: Soft. Bowel sounds present. Nontender. No organomegaly. Extremities: No edema, cyanosis or clubbing. Bilateral deep pulses present.

PHYSICAL EXAMINATION:  The patient is a very pleasant, awake, alert, and oriented (XX)-year-old female. Her blood pressure is 138/86, heart rate is 72 and regular, height is 5 feet and 2 inches, she weighs 138 pounds, respirations are 16 and regular, and O2 saturation is 96%. The patient feels safe at home. The patient ambulates with a slight limp on her left side in short steps. She has difficulty with both toe walking and heel walking. Her flexion and extension at the waist is limited to about 20 degrees forward and less than 10 degrees extension with complaint of lower back pain. She is able to twist from side to side and tilt from side to side with minimal complaints of pain into her left side. On palpation of her spine, she complains of pain in the lumbar area around L5. Also with complaint of pain that makes her wince into the SI joints, left worse than right. She also complains of severe pain with palpation into her hip joints, left worse than right. No complaints of pain into the paraspinal areas, left and right. She demonstrates good strength in her lower extremities, 5/5. Sensation is intact to light touch, and her deep tendon reflexes are 4+, equal, at the knee and 2+, equal, at the ankles. Her upper extremity reflexes are 1+, equal. Strength in upper extremities is also 5/5. Her breathing is nonlabored. Abdomen is protuberant and nontender. Skin is clean, dry, and intact. No pedal edema is palpated.

PHYSICAL EXAMINATION:  The patient is 5 feet 8 inches, 176 pounds. He has no pain with internal/external rotation of the hip. We can flex him up to about 90 degrees. He has negative anterior impingement, negative posterior impingement, negative FABER test. The patient has about 10 degrees of internal rotation and about 30-40 degrees external rotation. The patient does note mild discomfort with anterior impingement test but is not positive for pain. He is firing his iliopsoas, quad, hamstring, dorsiflexors, and plantar flexors. The patient has no pain over the greater trochanter. Negative Trendelenburg sign bilaterally and 5/5 abductor strength.

PHYSICAL EXAMINATION:  General: The patient is a well-developed, well-nourished male in no apparent distress. Head and Face: Normocephalic and atraumatic. There is no sinus percussion tenderness. There are no salivary gland masses. Cranial nerve VII is intact bilaterally. Eyes: Extraocular muscles are intact. Ears: There are no external ear lesions or masses. Hearing thresholds are grossly normal. Nose: There is no nasal septal deviation. There is no turbinate hypertrophy. There is no mucopurulent discharge. Oral Cavity and Oropharynx: There are no lesions or masses in the oral cavity or oropharynx. Palatal elevation is symmetric. Neck: There are no masses in the patient’s neck. There is a stable tracheotomy. There are no lesions or masses.

PE Sample 1

PHYSICAL EXAMINATION:  The patient’s blood pressure is 110/84, heart rate 72, weight 186 pounds, and temperature 98. Pain is 6/10. She is having a headache as well as pain in her joints. In general, her gait is stable and steady. She is a highly anxious, overweight, in no apparent distress. HEENT: No scleral or conjunctival abnormalities. Oropharynx: Clear without visible lesions. Normal salivary pooling. No parotid or submandibular glandular enlargement. Neck: Supple without lymphadenopathy. Heart: Regular, no extra heart sounds. Lungs: Clear. Abdomen: Soft, nontender, positive bowel sounds. Skin: No active rashes or edema at this time. Neurologic: Grossly nonfocal. Her musculoskeletal examination is entirely within normal limits without any active synovitis in the small or large joints. She has good range of motion throughout without chronic deformities, contracture deformity or laxity. The patient does not demonstrate any soft tissue tender points on examination today.

PHYSICAL EXAMINATION:  On examination, very pleasant man in no acute distress. He is sitting in a wheelchair. His blood pressure is 132/62, pulse 66, and respirations 18. He has prominent choreiform dyskinesias in all four extremities. He also has orofacial dystonia with mild spasm in the platysma and jaw dystonia. He has hypophonic speech. He has decreased upgaze. His face is symmetrical. Tongue is midline. He has generalized bradykinesia rated as 1 on all tasks in the upper extremities, very symmetrical picture. He has bradykinesia in the lower extremities rated as 0.5. He does have pretty normal tone. He can stand up with problems; he needed help. We were able to walk part of the corridor with significant problems. He was taking very short steps. He was not responding to verbal cueing. He also had Pisa syndrome with tilt of the trunk to the right side. He had mild antecollis.

PHYSICAL EXAMINATION:  Blood pressure 142/82, heart rate 74, weight 264, pain score 0/10. Repeat blood pressure 146/98. Extraocular movements are intact. Pupils are equal, round, and reactive to light and accommodation. Clear TMs bilaterally. Neck: Supple. Clear oropharynx. Lungs: CTAB. Heart: RRR. No murmurs. Neurologic: Intact upper and lower extremity motor, sensation, and DTRs. Gait: Unremarkable. Negative Nylan-Barany testing.

PHYSICAL EXAMINATION:  Vital Signs: Blood pressure is 124/88. Weight is 158 pounds. Pain score is 0/10. General: Pleasant male, healthy appearing, sitting up, in no acute respiratory or other distress. HEENT: Sclerae and conjunctivae are unremarkable. Oropharynx: Moist without lesions. Neck: Supple, no masses. Chest: Clear. Heart: Normal S1, S2. No murmurs or extra heart sounds. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. No organomegaly appreciated. Genitourinary: Normal phallus. Testicles without masses. No hernias. Rectal: Normal sphincter tone. Brown stool in the vault. No blood. Prostate: Smooth, bilobed. No discrete nodules or asymmetry. Extremities: No cyanosis, clubbing, edema. Skin: No suspicious hyperpigmented lesions. He has a few scattered moles over his anterior trunk and extensor surfaces of his arms. Neurologic: DTRs are symmetric. No focal deficits.

PHYSICAL EXAMINATION:  Her blood pressure was 122/82. Pulse was 68. Respiratory rate was 14. Pleasant woman, well developed, in no acute distress. Her neck was supple with no bruits. Cardiovascular: Regular rhythm. Extremities: No edema was noted. Neurologic Examination: The patient was alert. She was oriented x3. She had normal attention and language. No neglect or apraxia was noted. Cranial Nerve Examination: Pupils were equal and reactive. 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. Facial sensation and strength were normal. Decreased hearing on the right side. Palate and uvula elevate well and symmetrical. Decreased shoulder shrugs bilaterally. Tongue was midline. Motor strength was 5/5, except for giveaway weakness in both deltoids, right greater than left. We did not notice any spasticity or rigidity. No abnormal movements were noted. No dysmetria on finger-to-nose or heel-to-shin test. She had decreased sensation in her feet, up to knees, in both hands. She had abnormal position sense in her toes, decreased vibration in toes, ankles, and knees, slightly decreased in the hands. Reflexes were brisk throughout, including at her ankles, that were about +1. Her toes were mute. Her gait was slightly wide-based. She swaggered to either side. Positive Romberg. Unable to do tandem gait.

PE Sample 2

PHYSICAL EXAMINATION:  Well-developed, well-nourished man. He has much less edema around the left olecranon tip. There is no erythema today. He has full range of motion with some pain at full flexion and pain with pressure right over the olecranon tip. There was no antecedent trauma.

PHYSICAL EXAMINATION:  The patient is generally well appearing and in no acute distress. Facial examination reveals no asymmetry, swelling or lesions. He is nontender to palpation throughout his jaws. He has normal temporomandibular joint function, including maximal incisal opening. There is slight crepitus noted with the left temporomandibular joint. He is nontender to palpation throughout his muscles of mastication, including temporalis muscles. Intraorally, his dentition is heavily restored, however, healthy appearing. We see no gross decay. He is nontender to palpation or percussion of any of his right mandibular molars. Palpation of the posterior buccal vestibule does seem to elicit the discomfort he is experiencing. This seems almost to be a trigger point for him. The gingiva is entirely healthy in this location. Tongue, floor of mouth, and oropharynx are unremarkable. Neck is palpable. Cranial nerves II through XII are grossly intact.

PHYSICAL EXAMINATION:  Height 5 feet 6 inches, weighs 240 pounds. Healthy-appearing male, in no acute distress, is walking with a nonantalgic gait. He has significant pes planus with some mild hindfoot valgus on the left more than the right side. Good sagittal motion, good hindfoot motion, 5/5 strength in dorsiflexion, plantarflexion, inversion, and eversion. Ankle and hindfoot are stable to stress examination. Sensation is intact in all four dermatomes. Palpable pulse on the dorsum of the foot. His skin is supple. No abnormal callus formation. He is tender to palpation on the distal aspect of his plantar fascia, but not at the calcaneal origin. No tenderness at his Achilles, but Achilles is quite tight to straight leg examination, corrects on bent knee examination. He also has intrinsic hamstring tightness as well.

PHYSICAL EXAMINATION:  Examination of the feet reveals that the feet are both warm and dry. He does have some chronic venous insufficiency, and the feet have some mild to moderate swelling that is diffuse. The great toe on the left is exquisitely tender. The one on the right is tender but less severe from my examination. His toenails have chronic onychomycosis. They are thickened and dystrophic. The toe on the left is very reddened, less so on the great toe on the right. Feet are otherwise warm and dry. No other visible skin breaks are noted. There is no sign of any cellulitis at this point. It is difficult for him to wriggle his toe due to the pain.

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