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

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.

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.

The post Physical Exam Template Examples appeared first on Medical Transcription Sample Reports.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.2, pulse 106, respirations 20, blood pressure 142/90, and pulse ox 97% on room air.
GENERAL: This is a morbidly obese (XX)-year-old Hispanic female patient who is awake and alert, sitting on the gurney, resting comfortably, nontoxic.
HEENT: The head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. The right canal has pain with manipulation of the tragus and the pinna. The canal is edematous, unable to visualize the TM secondary to edema. In the left ear, the canal is clear without erythema, edema or discharge. TM is intact, pearly gray, sharp cone of light. There is no pain with manipulation of the pinna or the tragus.
NECK: Supple without meningismus. No lymphadenopathy noted.
LUNGS: Clear to auscultation, equal breath sounds bilaterally. No wheezes, rales, rhonchi, crackles or stridor noted. Respiratory excursion is symmetrical.
ABDOMEN: Soft, nontender, nondistended, positive bowel sounds all four quadrants. No guarding or rebound noted.
EXTREMITIES: On examination of the right knee, there is no erythema, edema or ecchymosis noted. The patient has point tenderness on the lateral and anterior portions of the knee. She complains of increased pain with range of motion and weightbearing. She denies numbness or tingling. Range of motion is limited secondary to pain. She has a good pedal pulse, brisk capillary refill, no obvious deformities, no crepitus noted.

PHYSICAL EXAM:
VITAL SIGNS: Blood pressure is 106/68, pulse 74, respirations 18, pulse ox 97% on room air, and temperature 98.4.
GENERAL: The patient is an otherwise healthy, well-developed, well-nourished (XX)-year-old female who is alert and oriented x3, nontoxic, in no apparent distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. The patient has no nystagmus. Ears: No tragal, mastoid or pinna tenderness. Canals/ears essentially normal. Nares patent. Oropharynx reveals bilateral tonsillar adenopathy and exudate with a slightly bilateral enlarged palate. His uvula is midline; it is not shifted or deviated, it is not edematous. He has no hot potato voice. He is not drooling. He has no trismus, no stridor.
NECK: Supple without anterior cervical lymphadenopathy.
LUNGS: Clear to auscultation, all fields. There is no evidence of distress.
HEART: Reveals normal sinus rhythm, no rubs or gallops.
ABDOMEN: Soft, nondistended, and nontender.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 97.4, pulse 78, respirations 18, O2 sat 99% on room air, and BP 130/86.
HEENT: The patient has just some slight scleral erythema. He is noted to have some cobblestoning of the inferior conjunctivae. The patient’s pupils are 2-3 mm equal, round, and reactive. There is no evidence of any drainage from his eyes at this time. His TMs are clear. His nares show some clear rhinorrhea.
CHEST: No retractions.
LUNGS: Clear with good equal breath sounds.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nondistended. Positive bowel sounds, nontender.
SKIN: No evidence of rash.

PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the emergency department today, temperature is 98.8. Blood pressure is 172/110; on manual recheck, it is 154/108. Pulse 100, respiratory rate 22, and O2 saturations 96% on room air. Visual acuity is 20/25 in the right eye and 20/30 in the left eye.
GENERAL: This is a (XX)-year-old well-developed, well-nourished Asian male in no acute distress. He is awake, alert, and oriented x3. He is pleasant and cooperative with the exam.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. His extraocular muscles are intact. He does not have any consensual photophobia or pain with accommodation. He is noted to have significant conjunctival injection bilaterally, right greater than left, with clear tearing to each eye. He also has some yellowish-appearing drainage from the right eye. There is no periorbital edema or evidence for cellulitis. No hordeolum appreciable and no foreign bodies appreciable. The globes appear to be intact.

PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 134/88, pulse 132, respirations 18, temperature 101.2, and pulse ox on room air is 93%.
GENERAL: This is a well-developed, well-nourished Hispanic male in no acute distress. He is alert and oriented x3 and does not appear postictal.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. Ears are clear with no hemotympanum. The patient does have a large, deep 3-4 cm laceration noted to the right dorsal tongue, which appears old. There is some fibrinous exudate appreciated here as well as some purulent drainage. He does also appear to have scarring noted to the lateral aspects of the tongue from repetitive biting. He is handling his secretions well.
NECK: Supple without lymphadenopathy.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, and nontender.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Otherwise, warm, dry, and intact.
MUSCULOSKELETAL: There is no C, T, L, S midline tenderness. He moves all four extremities equally and ambulates without difficulty.
NEUROLOGIC: Cranial nerves II-XII are tested and intact. He has full 5/5 strength with resisted movement in all muscle groups of the upper and lower extremities. Sensation is intact throughout to light touch. There are no focal neurologic deficits.

PE Sample 1

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/70, pulse 86, respirations 18, temperature 97.2 degrees, and pulse ox on room air is 97%.
GENERAL: This is a well-developed, well-nourished Asian female, in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist.
NECK: Supple.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: The patient has scattered areas of confluent erythematous papules noted to the left face, more mildly to the right face, left neck, and right lower abdomen. There are no vesicles noted. These are not distributed in a linear fashion; however, it does appear consistent with a contact dermatitis. She also has a few scattered excoriated macules noted to the right posterior calf with no evidence of secondary cellulitis. These appear consistent with mosquito bites, as reported by the patent. There is no burrowing noted. Palms and soles are spared. No involvement of the oral mucosa. No evidence of secondary bacterial infection. Skin is otherwise warm, dry, and intact.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/80, pulse 72, respiratory rate 18, temperature 97.8, and O2 sat 99%.
GENERAL: The patient did not appear toxic or ill.
HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are fully intact. Oropharynx is clear. No erythema. Uvula is midline. Tonsils are not inflamed. No submandibular, sublingual or buccal space swelling. No difficulty tolerating her secretions. No hoarseness or stridor.
LYMPHATIC: No lymphadenopathy.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, no cyanosis, and no edema.
SKIN: Warm, dry, and intact.
PSYCHIATRIC: Alert and oriented x4.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/88, pulse rate 94, respirations 24, temperature 98.2, and O2 sat 97%
GENERAL: The patient is alert and oriented x4, in no acute distress, does not appear toxic or ill, is uncomfortable.
HEENT: After the pain was controlled, we were able to get a better exam, which showed pupils to be equal, round, and reactive to light. Extraocular muscles were fully intact. The patient denies having any hyphema or hypopyon. The patient did not have any corneal abrasions. Ocular pressures by Tono-Pen were 18 on the right and 16 on the left.
NECK: The patient has full range of motion of the neck without any pain. She has no meningismus, no nuchal rigidity. Negative Brudzinski. Negative Kernig.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended, positive bowel sounds.
EXTREMITIES: No clubbing, no cyanosis, no edema.
SKIN: Warm, dry, and intact.
PSYCHIATRIC: Alert and oriented x4.
LYMPHATICS: No lymphadenopathy.
VASCULAR: Good pulses throughout all four extremities.

PE Sample 2

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.4, pulse 82, respiratory rate 18, blood pressure 128/88, and pulse ox 97% on room air.
GENERAL: This is a well-appearing Hispanic gentleman in no acute distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. His conjunctivae and sclerae are severely injected. The lids are inverted demonstrating no foreign body. His extraocular muscles are intact. His periorbital areas are puffy, but no erythema, fluctuance, induration or pain to palpation. He had tenderness over his TMJs bilaterally with palpable swollen rubbery lymphadenopathy that was tender to palpation. His TMs were clear bilaterally. No erythema, effusions or exudate. He had some shotty lymphadenopathy in his anterior cervical chain. He did not have evidence of trismus. He had normal occlusion. He did not have tenderness when biting on a tongue blade, and we were able to break a tongue blade between his teeth. His uvula was midline. His palate was symmetrical. He did not have any ulcers or lesions in his mouth.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds.
EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or edema.
NEUROLOGIC: Awake, alert, and oriented x4. His motor and sensory was grossly intact.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 94/60, pulse 96, respirations 18, temperature 98, and O2 sat is 97%.
GENERAL: The patient is alert and oriented x3, in no acute distress, nontoxic in appearance, ambulatory in the emergency department.
HEENT: Normocephalic and atraumatic. PERRLA, EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted.
NECK: Supple without lymphadenopathy. No spinous process tenderness of the C-spine.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Positive bowel sounds in all four quadrants, soft, nontender.
EXTREMITIES: She has 2+ pulses in all extremities. The patient does have some ecchymosis noted to her bilateral lower extremities. There is no tenderness to palpation of the patellae bilaterally. Negative valgus, negative varus, negative Lachman, negative drawer sign. Full range of motion of all extremities. No edema, erythema, warmth to touch or deformity noted.
BACK: Negative CVA tenderness. No spinous process tenderness of the cervical, thoracic, and lumbosacral spines.
SKIN: Warm and dry to touch.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/76, temperature is 97, pulse 88, and respirations 18. The patient’s pulse oximetry is 97% on room air.
GENERAL: The patient is a (XX)-year-old male, in no acute distress, A&O x3.
HEENT: Head is normocephalic and atraumatic. There is no facial swelling. No erythema or warmth on exam. Eyes: EOMs intact bilaterally. Pupils are equal, round, and react to light. Ears: TMs and canals are clear. Nares are patent. Pharynx patent. Oral mucosa pink and moist. Dental examination reveals tenderness with palpation and percussion over the left maxillary lateral incisor, which is obviously decayed. There is no evidence of any periodontal abscess. There is no facial swelling. No erythema or warmth on exam. No trismus.
NECK: Supple. No lymphadenopathy. Good full range of motion of the cervical spine.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation in all lung fields.
SKIN: Natural in color. Capillary refill is brisk. There is no exanthem.

The post Normal Physical Exam Template For MTs appeared first on Medical Transcription Sample Reports.

PHYSICAL EXAMINATION:
GENERAL: The patient is well developed and nontoxic.
VITAL SIGNS: Temperature 98.2, pulse 84, respirations 18, blood pressure 174/100, room air pulse ox 96%; that is within normal limits.
HEENT: Nonicteric sclerae, PERRLA, EOMI. Oropharynx clear. Moist mucous membranes. Conjunctivae appear well perfused.
CHEST: Chest wall is nontender.
HEART: Regular rate and rhythm without murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
GENITAL: Normal testicular lie. No signs of ecchymosis. There is some blood from meatus of this noncircumcised male. No crepitation. There is no obvious trauma to the phallus that is visible from the exterior. It is nontender.
RECTAL: Deferred.
SKIN: No rash, no excessive bruising, petechiae, or purpura.
NEUROLOGIC: Cranial nerves II-XII intact without motor/sensory deficit.

PHYSICAL EXAMINATION:  VITAL SIGNS: Blood pressure 138/84, pulse 106, respiratory rate 18, temperature 98.2, and pulse ox 99% on room air. GENERAL: The patient is awake, alert, and oriented, in no apparent distress. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear. The oropharynx is clear with pink moist mucous membranes. NECK: Supple. There is no lymphadenopathy. MUSCULOSKELETAL: With full range of motion in all four extremities and all joints, muscle groups. No joint deformity or redness with the exception of the right index DIP joint. SKIN: Warm and dry, no evidence of rash. The patient has a 1.5 cm laceration present over the DIP crease on the palmar surface, volar surface, of his right index finger with some significant scar tissue formed. He has difficulty in flexing this joint. There is no redness or purulence noted or expressible. Sensation is intact distally. NEUROLOGIC: Intact. Moving upper extremities symmetrically and spontaneously and following commands.

PHYSICAL EXAMINATION:
VITAL SIGNS: Height is 5 feet 6 inches. Weight is 136 pounds. Blood pressure is 120/66, pulse is 68, respirations are 16, and temperature is 98.2 degrees.
GENERAL: This is a well-developed female in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Conjunctivae are pink. Tympanic membranes are within normal limits bilaterally.
HEART: Cardiac exam reveals a regular rhythm and rate without murmur or gallop. There is no carotid or abdominal bruits.
BREASTS: Breast exam reveals no masses, skin changes, or axillary adenopathy.
ABDOMEN: Reveals normoactive bowel sounds, soft, nontender, no organomegaly.
PELVIC: Exam reveals normal external female genitalia. She has a normal cervix, small uterus, no adnexal fullness.
EXTREMITIES: Lower extremities reveal no edema, 2+ pulses.
BACK: Low Back: The patient is tender to palpation over her left SI joint, more than on the right side. She has good range of motion of both hips. She has a negative straight leg raise. She has 5/5 strength of her legs. Her gait is normal.

PE Sample 1

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/72, pulse 74, respirations 18, O2 sat 100% on room air, and temperature is 99.2.
GENERAL: Otherwise healthy, well-developed, well-nourished, (XX)-year-old female who is alert and oriented x3, nontoxic, in no apparent distress.
EXTREMITIES: On examination of the left lower extremity, the patient has a very small, approximately nickel-sized abscess to the anterior aspect of her left lower extremity with some small surrounding cellulitis. She has no lymphangitis, has no bleeding or drainage noted at this time. She has no posterior pain or swelling. She has no circumferential cellulitis. Full range of motion of her extremity. She is able to ambulate with normal sensation and good pulse.

PHYSICAL EXAMINATION:
GENERAL: The patient is well developed and nontoxic.
VITAL SIGNS: Temperature is 98.6, pulse 92, respirations 18, blood pressure 138/90, room air pulse ox 95% is within normal limits.
HEENT: Nonicteric sclerae, PERRLA, EOMI. Oropharynx clear. Moist mucous membranes.
CHEST: Chest wall nontender.
HEART: Regular rate and rhythm. No murmurs, clicks, gallops, rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly, no pulsatile mass, no Murphy’s sign. No Cullen’s or Grey Turner’s sign.
RECTAL: Deferred.
GENITAL: Deferred.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Cranial nerves II-XII intact without motor, sensory, or cerebellar deficit, no asterixis.
SKIN: No rash.

PE Sample 2

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 110/66, pulse 128, respiratory rate 18, temperature 99.6, O2 sat 95% on room air.
GENERAL: The patient is alert and oriented, in no apparent distress. She is pleasant and conversant in full sentences.
HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes are moist without lesions.
NECK: The patient has no noted JVD. No adenopathy is appreciated.
CHEST/LUNGS: The patient does have a port intact to her chest without any surrounding evidence of erythema or infection. Her lungs are clear bilaterally without rhonchi, rales, or wheezes. There is no subcutaneous air appreciated. There is no tenderness to the chest wall.
HEART: The patient has a regular rate and rhythm. No murmurs, rubs, or gallops are appreciated. Distal pulses are 2+. No carotid bruits appreciated.
ABDOMEN: The patient’s abdomen is completely soft, nontender, and nondistended. Bowel sounds are positive. No organomegaly is appreciated. No masses are appreciated. There are no peritoneal signs. There is no Murphy’s sign.
EXTREMITIES: The patient has no peripheral edema. There is no focal long bone tenderness or deformity.
SKIN: The patient’s skin is warm and dry, without rashes or lesions.
PSYCHIATRIC: The patient has normal mental status and has an appropriate affect.
NEUROLOGIC: The patient has 5/5 strength to the upper and lower extremities bilaterally. Sensation is intact throughout. Gait is within normal limits. Deep tendon reflexes are 2+ in all four extremities. There are no deficits to the cranial nerves.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 96/54, temperature 98.6, pulse 104, respirations 16, 99% on room air.
GENERAL: Awake, alert, comfortable appearing, in no acute distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. No nasal discharge. No facial trauma. Intraoral exam shows moist mucous membranes with no tonsillar enlargement or exudate. Tympanic membranes are normal. The canals are clear.
NECK: Supple with no cervical lymphadenopathy No meningismus. No goiter.
HEART: Regular rate without murmur, rub, or gallop.
LUNGS: Equal breath sounds bilaterally with no wheezing, rales, or rhonchi. There is no chest wall tenderness or instability.
ABDOMEN: No external sign of injury. Bowel sounds are present. Abdomen is soft, nontender. No rebound, no guarding, no rigidity. There are no palpable masses. There is no flank pain on exam.
EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis, and no edema.
SKIN: No rash.
PELVIC: Pelvic examination was performed. Uterus was slightly enlarged. There was absolutely no blood whatsoever or discharge from the cervix. She has no adnexal masses or tenderness noted.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 172/88, temperature 98.4, pulse 112, respirations 26, SaO2 is 92% on room air.
GENERAL APPEARANCE: The patient is alert and oriented, in no acute distress.
HEENT: PERRLA. Extraocular movements are intact. Sclerae are anicteric. Conjunctivae are clear. ENT: Ears, nose, and throat are clear.
NECK: Supple without adenopathy. Thyroid is normal. Carotids free of bruit.
LUNGS: Coarse basilar rales are noted.
HEART: Regular rate and rhythm without murmur, rub or gallop. Slight jugular venous distention is present.
ABDOMEN: Soft and nontender. Active bowel sounds. No organomegaly.
SKIN: Clear, free of rash.
NEUROLOGIC: Cranial nerves II through XII intact. Distal, motor, and sensory exam is grossly intact.
MUSCULOSKELETAL: Full range of motion of all 4 extremities without pain. Calves are nontender with a negative Homans’. She does have profound kyphosis of the thoracic spine.

PHYSICAL EXAM:
VITAL SIGNS: Temperature is 97.8, BP is 116/86, pulse 72, respirations 18, O2 sat is 98% on room air.
GENERAL: The patient is a well-developed, well-nourished Hispanic male who is alert and oriented. He is in no acute distress.
HEENT: Head is normocephalic, atraumatic. The patient’s eyes are PERRLA, EOMI. Oropharynx is clear. Uvula is midline.
NECK: Supple, nontender. No lymphadenopathy present.
HEART: Regular rate and rhythm, equal S1, S2. No murmur, rub or gallop.
LUNGS: Clear bilaterally. No wheezes, rhonchi or rales.
ABDOMEN: Soft, nontender, and nondistended with active bowel sounds.
EXTREMITIES: There is no clubbing, no cyanosis. His radial, DP, and PT pulses are intact and symmetric. In the patient’s right lower extremity, he does have an incision site midline across his right knee. There are no staples or sutures in place. There is no wound dehiscence, no evidence of erythema, edema, no evidence of cellulitis or purulent drainage. He has no fluctuance with palpation. On the patient’s left lower extremity, essentially, distally from the mid shaft of his tibia distally down to the toes, it is erythematous and edematous. It is minimally tender with touch. There is no lymphangitic streaking. No palpable cords or masses appreciated with palpation of his calf, but he does have tenderness with palpation of his calf muscle. The edema is only midshaft up the tibia. He has good palpable femoral pulses and has full range of motion with plantarflexion, dorsiflexion against resistance, as well as flexion and extension of his left knee.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 114/66, pulse 86, respirations 22, temperature 100.6, pulse ox is 95%.
GENERAL: She is awake, alert, and oriented in mild distress secondary to pain from her buttocks.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs, or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
RECTAL: Does not reveal any mass inside the rectal vault. There is tenderness to palpation of the abscess area. The abscess does not seem to enter the rectal area or the genital area.
INTEGUMENTARY: The patient has a large 6.5 cm x 6 cm abscess on her left buttock with a surrounding area of cellulitis.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.

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PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 142/96, pulse 102, respiratory rate 18, temperature 97.8, and pulse ox is 97% on room air.
GENERAL: The patient is awake, alert, and oriented, in no apparent distress, resting comfortably on the bed. She has a very nasal voice.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Conjunctivae are clear. Oropharynx is clear and pink with moist mucous membranes. Her tympanic membranes have a serous fluid behind both of them, but there is no thickening of the tympanic membrane on either side. She has no opacity. No redness.
NECK: Supple without lymphadenopathy. No tracheal deviation. She does have some mild thyromegaly.
LUNGS: Clear to auscultation bilaterally. No wheezes, rubs, rhonchi, rales, or stridor.
HEART: Normal S1, S2. Regular rate and rhythm, no murmurs.
ABDOMEN: Normoactive bowel sounds, soft, nontender, nondistended, no masses, no hepatosplenomegaly.
EXTREMITIES: With full range of motion in all four extremities, no joint swelling or redness.
SKIN: Warm and dry, no evidence of rash.
NEUROLOGIC: Intact. Moving all four extremities symmetrically and spontaneously and is following commands. She is speaking in full, fluent sentences.

PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly Hispanic female, alert, in no acute distress.
VITAL SIGNS: Blood pressure 168/84, heart rate 90, and respiratory rate 20 on pressure support of 15 with tidal volumes of 450-600 and minute ventilation of 9-10 liters, and temperature 98.6 degrees.
HEENT: The patient has a Shiley size #8 tracheostomy tube in the midline. Posterior pharynx is clear. Nasopharynx shows a small amount of clear nasal drainage. Conjunctivae clear.
CHEST: She has bilateral coarse rhonchi. Prolonged I:E ratio. No stridor. No use of accessory muscles at rest.
CARDIOVASCULAR: Difficult to auscultate over the breath sounds. She has a regular rate and rhythm. No murmur or gallop is appreciated. No palpable heaves or thrills.
ABDOMEN: Soft. She complains of some mild epigastric tenderness with palpation. No guarding. No palpable masses. Normoactive bowel sounds.
EXTREMITIES: She has no clubbing or cyanosis. She has a trace edema of the lower extremities. No discrepancy in cast size.
NEUROLOGIC: She is alert and oriented. She has incomplete quadriparesis with some severe left lower extremity weakness with minimal mobility to move the toes unopposed and right-sided weakness of lower extremities with ability to raise her knee off the bed unopposed.

PE Sample 1

PHYSICAL EXAM: Vital signs revealed a blood pressure of 106/62, respirations of 16 breaths per minute, and a pulse rate of 72 beats per minute. On neurologic examination, the patient is alert and oriented. Simple attention is intact. Sustained attention, however, is poor. The patient has difficult registering four-word pairs, but does it after three trials. At one minute, the patient recalls none spontaneously and gets three with cueing after five minutes. He recalls one of four word pairs spontaneously. He gets to three with multiple-choice cues. Interestingly, he can count from 40 to 0 with no mistakes or errors in about 40 seconds. Word list generation is 13 in a category, which is substandard. Long-term memory is mildly impaired for past presidents, past/current events, etc., and details about local politics. Language is fluent. Visuospatial was not examined, and comprehension was normal. Problem solving is moderately impaired. Insight is moderately impaired, and organization and executive skills are moderately impaired with moderate impairment in safety awareness. He is, however, able to generate some problems solving and is able to generate consequences to some decisions that need to be made such as the ability to live at home and direct his own care. He says last night that when he was confusional or agitated, he was in fact refusing to have the IV medications given to him, but they were given anyway. His cranial nerve examination reveals mildly saccadic pursuits for full vertical and horizontal ductions. Fundi could not be well visualized. Fields are full. He has negative glabellar, negative jaw jerk. The rest of his cranial nerves were intact. He has no nuchal rigidity. His motor examination shows symmetric strength throughout with no cogwheeling, mild bradykinesia with no severe akinesia. No tremor at rest. Reflexes are 2+ throughout. Toes are equivocal. He does not have primary sensory loss to vibration, JPS, or pinprick that we could tell. The patient goes from sit to stand by pushing on the wheelchair and cannot arise without doing that. He has very narrow limits of stability posteriorly and delayed step response. He ambulates in a crouched suspensory posture and has mild freezing when he starts out, but no freezing on turns. Turns are not particularly wide. He has no festination in his gait. Of note, he is not hypomanic. He does not have decreased blink frequency, and he has a negative glabellar.

PE Sample 2

PHYSICAL EXAMINATION: General: The patient is a well-developed and well-nourished (XX)-year-old, awake, alert, and oriented x3 with mild distress. Vital Signs: Blood pressure is 136/86 mmHg, pulse is 72 beats per minute, respirations are 18 breaths per minute, and the patient is afebrile. Skin: Warm and dry. HEENT: Normocephalic and atraumatic. PERRLA. The fundi are more or less okay. The conjunctivae are pink, and the sclerae are anicteric. Neck: Supple. There is full range of motion. The carotids are 2+ bilaterally without any bruits being heard. The lymph nodes are negative. Thyroid is nonpalpable. The trachea is midline. Heart: Regular sinus rhythm without murmur, gallop, or rub. Lungs: Clear to P&A. Abdomen: Normoactive bowel sounds, soft, positive tenderness in the left lower quadrant. There is no liver, kidney, or spleen and no other masses palpated. The abdominal aorta is palpated and is pulsatile but appears to be otherwise without an aneurysm. Extremities: No clubbing, cyanosis, or edema. She does have some varicose veins in the extremity. Neurologic/Psychiatric: There are no acute changes.

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PHYSICAL EXAMINATION: On examination, he looks well. Blood pressure 112/72 and pulse 72. Head and neck exam unremarkable. No lymphadenopathy or jaundice. Precordium is quiet. Normal heart sounds. No added sounds or murmurs. Lungs clear to auscultation. No crackles or wheezes. Abdomen is benign. No obvious organomegaly or masses appreciated. No peripheral edema evident.

PHYSICAL EXAMINATION: On examination, he looks his stated age. Blood pressure 130/70 and pulse 80. Head and neck exam unremarkable. No lymphadenopathy or jaundice. Precordium is quiet. No heaves or lifts. PMI is normal. S1, S2 is normal. No S3, no S4, no murmurs. Lungs reveal diminished breath sounds to the bases and slight crepitation. No other adventitious sounds. Abdomen is benign. No obvious organomegaly or masses appreciated. No peripheral edema evident.

PHYSICAL EXAMINATION: On exam, blood pressure 124/58, heart rate 66, sats are 98% on room air. Head and neck exam normal with no signs of lymphadenopathy or stigmata of chronic liver disease. Lungs are clear with no crackles or wheeze. He had normal S1 and S2. No extra heart sounds or murmurs. Abdomen was benign and slightly distended. The patient did have some very mild right lower quadrant pain with deep palpation; however, there were no peritonitic signs and no masses palpated. Extremities were warm and well perfused. There were no focal neurological changes.

PHYSICAL EXAMINATION: The patient has no change in vascular, neurologic, or musculoskeletal since last visit. The patient has a Tailor’s bunion and hallux hammer toes and keratoses. Neurologically intact.

PHYSICAL EXAMINATION: Blood pressure 142/72, temperature 98.4. The patient is alert, oriented, and conversant. Does not appear ill in any way. HEENT: Nasal pallor with mild edema. No exudate. Normal TMs and oropharynx. Neck: Supple. No adenopathy, thyromegaly. Heart: Regular rate and rhythm. S1, S2. No murmurs. Lungs: Clear to auscultation.

PHYSICAL EXAMINATION: Blood pressure 104/64, heart rate 72, weight 164 pounds, temperature 99.6. Full range of motion of neck, shoulders, elbows, wrists, knees, and ankles. There is no swelling or synovitis in these joints, and joints are hypermobile. Lungs are clear. Regular rate and rhythm. S1, S2. Abdomen is soft and nontender. No clubbing, cyanosis, or edema. No positive straight leg at today’s visit.

PE Sample 1

PHYSICAL EXAMINATION: Blood pressure 126/70, heart rate 82, weight 232. Neck: Supple. Lungs: CTAB. Heart: RRR. No murmurs. Abdomen: Benign. Extremities: Trace bilateral pitting edema.

PHYSICAL EXAMINATION: The patient is awake, alert, and oriented. She is in ill tempered and bad mood. She appears to be angry and somewhat confrontational. She has a very loud voice today. She has a pain level of 10/10 with significant pain behavior.

PHYSICAL EXAMINATION: No distress. Vital Signs: Stable, afebrile. There is no spinous process tenderness or spasm. Straight leg raise was negative. Neurologic, cardiovascular features are unremarkable. Lower extremities with full sensation, pulses, reflexes, and motor function. He can almost touch his fingers to his toes, which is his usual range of motion. Lateral bending and lateral rotation were normal.

PHYSICAL EXAMINATION: CVS: S1, S2, regular. Lungs: Clear to auscultation. She is tender on palpation on her left side paraspinally and tight, and is tender at her SI joint, tender at her hip area and, by pressure on the hip, we actually reproduced the sciatica.

PHYSICAL EXAMINATION: On examination, the patient is a short, stout woman. She has dentures. Examination of head and neck, otherwise, was unremarkable. The patient has a Mallampati 2 airway. Chest was clear with good air entry bilaterally. Heart sounds were normal. Could not hear any murmurs. Blood pressure today was 150/84, and her oxygen saturation was 98% on room air. Examination of her abdomen revealed it to be soft. There was tenderness on deep palpation in the epigastric area and in the left lower quadrant. Could elicit no significant symptoms on the right side. Rectal examination not done.

PHYSICAL EXAMINATION: On examination, she looks reasonably well and was in no distress at rest. Blood pressure was 152/86 mmHg with a regular heart rate of 84 beats per minute. Respiratory rate was 14 breaths per minute with an oxygen saturation of 100% on room air. Head and neck examination was unremarkable. Chest was resonant to percussion with clear breath sounds heard on auscultation bilaterally. Cardiovascular examination demonstrated normal heart sounds with no added sounds or murmurs present. No jugular venous distention nor any peripheral edema noted. All peripheral pulses were palpable. Abdomen was soft and nontender with normal bowel sounds present. There are no palpable masses nor hepatosplenomegaly evident. Neurologic exam was grossly intact.

PHYSICAL EXAMINATION: Blood pressure 152/86, pulse 66, respirations 18, and temperature 98.4. In general, the patient is a thin male in no acute distress. Pupils are equal, round, and reactive to light. Conjunctivae are pink. Tympanic membranes are within normal limits bilaterally. Oropharynx reveals no erythema or exudate. There is no supraclavicular or cervical adenopathy or thyromegaly. Chest is clear to auscultation bilaterally. Cardiac exam reveals regular rhythm and rate without murmur or gallop. No carotid or abdominal bruits. Abdomen reveals normoactive bowel sounds, soft, nontender, no organomegaly. On neuro exam, the patient is alert and oriented x3. Cranial nerves II through XII are intact. Gait is normal. Tandem gait is normal. Finger-to-nose is normal. Romberg is negative.

PHYSICAL EXAMINATION: On examination today, she is afebrile. Her blood pressure is 92/64. Heart rate is 72. Weight is 82 pounds. HEENT: Bilateral eardrums partially visualized because of wax. Oral mucosa is moist. Nasal mucosa is moist. No congestion. No lymphadenopathy. Lungs: Clear to auscultation. Heart: S1, S2 normal. Regular rate and rhythm. Abdomen is soft, nontender, nondistended. No rebound. No guarding.

PHYSICAL EXAMINATION: She is neurovascularly intact to sensation and motor. She has pain at the A1 pulley of the right ring finger with locking noted. Capillary refill is brisk. Normal skin turgor and texture.

PHYSICAL EXAMINATION: Blood pressure is 124/90, pulse 74, respirations 14. We do not appreciate any dominant mass or axillary lymphadenopathy in either breast. At the time of the exam, her nipples are both everted.

PE Sample 2

PHYSICAL EXAMINATION: The patient has pulses 2 for DP/PT bilateral, CFT 3 seconds. Neurologically grossly intact. Negative clonus. Negative Babinski. The patient has 4/5 dorsiflexion, plantarflexion, inversion and eversion to the left foot and 5/5 dorsiflexion, plantarflexion, inversion and eversion of the right foot. Range of motion 0 degrees dorsiflexion, 45 degrees plantarflexion, 10 degrees inversion and eversion. Positive and restricted pain upon range of motion of ankle joint noted. The patient has positive pain upon palpation proximally at the base of the fifth metatarsal along the course of the peroneal tendons. Positive tightness and tenderness along the lateral insertion of the tendoachilles level. Local edema. Positive tenderness upon palpation. There is scar tissue along the peroneal tissue as well as tendoachilles.

PHYSICAL EXAMINATION: Temperature 97.4, pulse 66, respirations 20, O2 sat 97% on room air, and BP 160/94. He does not appear acutely ill. He does have some audible nasal congestion. TMs are clear. Nares are clear with some slightly boggy nasal mucosa. Neck is supple. Chest shows no retractions. Lungs are clear with good equal breath sounds. Cardiac exam reveals regular rate and rhythm without murmur. Abdomen is soft, nondistended, positive bowel sounds, nontender in all four quadrants. Skin shows no evidence of rash.

PHYSICAL EXAMINATION: BP 152/78, temperature 98.4, pulse 82, respirations 16, and O2 sat 100% on room air. The patient is well developed, in no distress. Moist mucous membranes. Neck is supple, no JVD. Cardiac exam reveals regular rate and rhythm, S1, S2. The patient has an occasional end-expiratory wheeze, good air exchange. The patient’s abdomen is soft, positive bowel sounds. Slight tenderness in the left upper and left lower quadrants. No rebound, no guarding, no masses. Trace edema of the lower extremities. Rectal, heme negative, no masses.

PHYSICAL EXAMINATION: Temperature: 97.8. Pulse: 76. Blood pressure: 134/84. Weight: 184 pounds. There is no mucosal pallor. There is no icterus. There is no peripheral adenopathy. The heart reveals a regular rate and rhythm without murmur, rub or gallop. The lungs are clear to auscultation with no wheezing, rhonchi or rales. There is a bandage in the left upper anterior chest from removal of the former LifePort. The abdomen is soft and nontender with good bowel sounds. There is no hepatosplenomegaly, masses or ascites. There is no dependent edema.

OBJECTIVE: The patient is in no distress. Weight 142, blood pressure 132/62 with a pulse of 66 and irregularly irregular. Unable to elicit any orthostatic changes or symptoms by going from lying to standing. Provocative maneuvers do not create symptoms. Chest is clear. Neck shows restricted motion beyond 45 degrees, either to the right or the left, because of muscle spasm. Carotids are 1+ without bruits. There is no JVD or HJR. Heart: Irregularly irregular rhythm without murmur, gallop, or rub. Abdomen: Soft. Bowel sounds normal. Extremities: Without edema.

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