Physical Exam Section Words And Transcription Examples For Medical Transcriptionists

VITAL SIGNS: Temperature 98.5, pulse 68, respirations 21, BP 108/70, pulse oximetry 98% on room air. 
GENERAL APPEARANCE: Well-developed, well-nourished, nontoxic, ambulatory female. 
MENTAL STATUS: The patient is alert and oriented x3. Her Glasgow coma scale is 15. 
HEENT: Reveals normocephalic, atraumatic facies. Ears, eyes, nose, throat are all within normal limits. Mucous membranes are moist and pink. 
NECK: Supple, moderately tender to palpation with bilateral paracervical and trapezius musculature. Trachea is midline. 
LYMPHATICS: The patient exhibits no lymphadenopathy. 
CHEST: Examination of the chest reveals equal bilateral breath sounds. Clear to auscultation with normal chest wall excursion. 
HEART: Regular rate and rhythm without murmur, rub or gallop. 
ABDOMEN: Benign. 
BACK: Reveals a vague midline tenderness to the cervical and lumbosacral spine extending for approximately C2 through C4 as well as L2 through L4. There is no obvious deformity or step-off noted. The patient exhibits full, but painful range of motion of her neck and low back predominantly with flexion and extension of both. She is capable of axial rotation without deficit. 
EXTREMITIES: Reveals full range of motion of all extremities without deficit. The patient exhibits strong distal pulses, brisk capillary refill. 
NEUROLOGIC: Reveals no gross motor or sensory deficits. The patient is alert, cooperative and exhibits intact distal sensation in all extremities. 
INTEGUMENTARY: Without diaphoresis, rash or lesions. Skin is warm and dry to touch, normal tone and turgor. 

VITAL SIGNS: Blood pressure 118/82, pulse 82, respirations 19, temperature 97.4 and O2 saturation 99% on room air.
GENERAL: This is a well-developed, well-nourished male, not in acute distress, appears comfortable lying in bed.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular muscles are intact. No nystagmus. No scleral icterus. Oral mucosa moist and pink without erythema or exudate.
NECK: Supple, no JVD. No cervical lymphadenopathy.
LUNGS: Respirations are clear to auscultation bilaterally with equal chest wall expansion.
HEART: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs or gallops noted.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema noted.
BACK: He does have tenderness to palpation along the lumbar region.
EXTREMITIES: He has no saddle paresthesias on exam.
RECTAL EXAM: Normal rectal tone.

VITAL SIGNS:  On admission, temperature 98.5, blood pressure 142/89, pulse 105, respiratory rate 21, and O2 saturation 98% on room air. 
GENERAL: Well-developed, well-nourished female in some discomfort, but no acute cardiopulmonary distress. She is awake, alert and oriented x3. She is cooperative with exam. 
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. She does have some photophobia bilaterally, but no papilledema appreciable. No nystagmus. Her oropharynx is clear. Mucous membranes are moist and pink. 
NECK: Supple, nontender without lymphadenopathy. 
HEART: Regular rate and rhythm. 
EXTREMITIES: Pulses are symmetric and intact. 
LUNGS: Clear. 
ABDOMEN: Shows ileostomy with a bag in place. Initially, there were food contents within the bag and I did not appreciate bleeding. Later on, I did see a little bit of bright red blood oozing from the ostomy site. Stoma, however, is pink and there is no evidence of infection. Good bowel sounds throughout. No CVA tenderness bilaterally. 
SKIN: Intact without petechia. 
NEUROLOGIC: She has no focal neurologic deficits. Cranial nerves II through XII are grossly intact. Sensation is intact throughout. She is moving all four extremities. Follows complex commands, ambulates with a steady gait.

VITAL SIGNS:  Temperature 99.6, pulse 84, respiratory rate 22, blood pressure 134/92, pulse oximetry 98% on room air. 
GENERAL:  The patient is an alert female, resting comfortably. 
HEENT:  Head and face:  No facial plethora. No signs of trauma. Eyes:  Pupils equal and reactive to light bilaterally. Oral cavity pink and moist. There is no oropharyngeal erythema, no exudate. Uvula is midline. There is no swelling. No retropharyngeal swelling. 
NECK:  Supple. No lymphadenopathy, no jugular venous distention. There is no neck stiffness, no meningismus. 
HEART:  Regular rate and rhythm without murmur, gallops or rubs. 
LUNGS:  Clear to auscultation bilaterally without wheeze, rhonchi or rales. 
ABDOMEN:  Soft, nontender, nondistended, without masses. Bowel sounds are positive. There is no guarding, no rebound, no tenderness. 
EXTREMITIES:  Warm, nonedematous. No obvious deformity. 
NEUROLOGIC:  Cranial nerves II through XII are intact grossly. No focal neurologic deficits. Gait is normal. Deep tendon reflexes in upper and lower extremities are 2+ bilaterally. Sensation is intact to pinprick in upper and lower extremities bilaterally. Has 5/5 strength in upper and lower extremities bilaterally. 
BACK:  Nontender. There is no CVA tenderness. There is no step-off or point tenderness along the entire spine. There is no edema. 
RECTAL:  Exam deferred. 
GENITAL:  Genital examination is deferred. 
SKIN:  Warm, dry, noncyanotic, nondiaphoretic. Capillary refill is brisk.
MENTAL STATUS:  Answers questions appropriately.

VITAL SIGNS:  Blood pressure 118/82, pulse 102, respirations 18, and temperature 98%.
GENERAL:  A female who appears slightly older than her stated age, in a mild amount of distress.
HEENT:  Head is normocephalic and atraumatic. Pupils are reactive bilaterally. Extraocular movements are intact; however, with lateral deviation of the right eye, she does have increased pain on that side. Visual fields are full to confrontation. Oropharynx is unremarkable. On evaluation of the ears, she has no evidence of vesicles in the right ear; however, it is extremely painful to touch. The otoscope placed in external ear canal causes her a great deal of pain. Fluorescein staining of the right eye visualized under Wood's lamp revealed no evidence of dendritic cells or obvious abnormalities.
NECK:  Supple. Accessory nerve appears to be intact.
LUNGS:  Clear to auscultation bilaterally with no rubs, rhonchi or wheezes.
CARDIOVASCULAR:  Tachycardia, regular rhythm, no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.
EXTREMITIES:  No cyanosis, clubbing or edema. Strength is 5/5 throughout and symmetric bilaterally. On bilateral lower extremity exam, she has 5/5 strength but she does have objective numbness in the bilateral lower extremities, which is baseline for her due to her CIDP. No evidence of ataxia. There is no pronator drift. Reflexes 2+ symmetric bilaterally, upper and lower extremities.
NEUROLOGIC:  The patient is alert and oriented x4. GCS of 15. On cranial nerve exam, the patient does have no objective numbness in the V1, V2, V3 distribution; however, the patient does have painful and burning sensation with palpation of these areas. Hearing appears unimpaired. The patient is having increased pain to palpation of the pinna, tragus, and with the otoscope insertion of the external canal, there is a slight amount of facial droop but no dysarthria. Uvula and tongue are both midline.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Temperature 98.6. Blood pressure 134/62. Weight 148, which is stable. Height 5 feet 4 inches tall. O2 saturation is 96% on room air. Heart rate 72 and regular. GENERAL:  She is well appearing, in no distress, although coughing. HEENT:  Normocephalic and atraumatic. Extraocular movements are intact. Pupils are equal, round, and reactive to light. Mucous membranes are moist. Oropharynx clear. Tympanic membrane on the left is gray with normal light reflex; the right has some scarring, but is otherwise normal. No evidence of infection. NECK:  Supple with no bruits, no lymphadenopathy. Thyroid is nonpalpable. HEART:  Regular rate and rhythm, S1 and S2. No murmurs, gallops or rubs. LUNGS:  Clear throughout with no wheezes, crackles or rhonchi. BREASTS:  No dominant masses, no nipple discharge. Reviewed self-breast exam in detail. Axillae have no adenopathy. ABDOMEN:  Soft, nontender, and nondistended. GYNECOLOGIC:  Normal external genitalia. Pap was performed. I am able to easily put the brush into the os. The ovaries feel normal. Uterus is retroverted, is normal. On rectovaginal exam, no masses. She has a slight diminished rectal sphincter tone. EXTREMITIES:  No clubbing, cyanosis or edema.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Blood pressure 110/74, weight 146, temperature 98.6, pulse 74, height 66-3/4 inches.  GENERAL:  Alert and oriented x3.  No acute distress.  SKIN:  Intact.  Multiple cherry angiomas noted.  No suspicious skin lesions noted.  HEENT:  Tympanic membranes are without erythema or injection.  Nares are patent.  Nasal mucosa is normal.  Pupils are equal, round, and reactive to light.  EOMs are intact without nystagmus.  Funduscopic examination is normal.  Pharynx is without erythema or exudate.  NECK:  Supple without nodes.  No thyromegaly or thyroid nodules.  No carotid bruits.  LUNGS:  Clear to auscultation.  No rales, rhonchi or wheeze.  HEART:  Regular rate and rhythm.  S1 and S2 auscultated.  No S3, S4.  No murmur.  No palpable thrills.  BREASTS:  Symmetric.  No nipple discharge.  No dimpling noted in the breast tissue.  No masses.  No axillary nodes.  No frank pain.  ABDOMEN:  Soft and nontender.  Bowel sounds x4.  No masses.  No hepatosplenomegaly.  PELVIC:  External genitalia without nodes, erythema, lesions, swelling.  Internal examination is with rugae.  Cervix is multiparous.  Scant clear discharge is noted.  Friable.  Pap smear obtained.  Digene HPV testing obtained.  On bimanual examination, uterus is midline.  Adnexa nontender and without masses.  RECTAL:  Rectum is with good rectal tone.  No masses.  Guaiac negative.  EXTREMITIES:  With varicose veins of lower extremities.  No cyanosis, clubbing or edema.  Peripheral vascular system is intact.  NEUROLOGIC:  Cranial nerves II through XII are grossly intact.

VITAL SIGNS:  Blood pressure 180/79, pulse rate of 64, respiratory rate of 21, temperature 98.6 and 98% on room air.
GENERAL APPEARANCE:  This is a well-developed and well-nourished female, in no acute distress.
HEENT:  No external signs of head trauma. Pupils are equal and reactive to light. No scleral icterus or pale conjunctivae. Oral  mucosa is moist. Trachea is midline. No carotid or vertebral bruits.
NECK:  Neck is supple. She had paraspinal tenderness upon palpation of her levator scapulae muscle and scalene muscles. No pulsatile mass was noted. No lymphadenopathy.
LUNGS:  Clear to auscultation.
HEART:  Bradycardic but no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender and nondistended. Positive bowel sounds.
EXTREMITIES:  No extremity swelling.
SKIN:  No rashes or petechiae.
NEUROLOGIC:  GCS was 15. Cranial nerves II through XII are grossly intact. No facial droop. No pronator drift. No dysmetria or ataxia. Symmetric patellar reflex. Negative  Babinski sign. Negative Romberg sign. Normal steady gait.

PE Sample # 2             

PHYSICAL EXAMINATION:  VITAL SIGNS:  Temperature 99.6, heart rate 91, respiratory rate 19, and blood pressure 133/88.  GENERAL:  She appears her stated age in no acute distress, euthymic affect, smiling, talkative and alert and oriented x4.  HEENT:  Pupils are equal, round and reactive to light and accommodation.  Extraocular muscles are intact.  Oropharynx is unremarkable.  NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  LUNGS:  Clear to auscultation bilaterally.  No rales or rhonchi.  No labored breath.  HEART:  Regular rate and rhythm without murmurs, rubs or gallops.  ABDOMEN:  The patient is obese with moderate to diffuse tenderness to palpation.  Nondistended.  Positive bowel sounds.  No palpable masses.  EXTREMITIES:  Good capillary refill bilaterally.  One fingerbreadth is under cast.  SKIN:  Nonicteric.  She does have a right lateral thigh laceration with the sutures intact, without evidence of infection.  NEUROLOGIC:  Her mini-mental status exam is 30/30.  Cranial nerves II through XII are intact.  Light touch is intact.  Proprioception is intact bilaterally.  The patient is 5/5 throughout in her upper extremities.  At the hip flexors, she is 3 on the right and 2+ on the left, knee extensors 4- bilaterally on the right, and EHLs 4+ bilaterally.  On the left, dorsiflexion is 5 and plantar flexion is 5.  It is unable to be tested on the right secondary to the cast.  The toes are downgoing.  No clonus.  The patient had normal tone without atrophy or spasticity in upper and lower extremities bilaterally.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Temperature 98.6, heart rate 64, respiration 18, blood pressure 94/58, oxygen saturation 99%.  GENERAL APPEARANCE:  Not acutely distressed, but she is feeling tired. She has poor eye contact. She is reluctant to answer questions.  HEENT:  NC/AT. PERRLA.  NECK:  Supple. No thyroid goiter.  LUNGS:  She has bibasilar fine crackles.   HEART:  RRR. Normal S1, S2. She has systolic ejection murmur of 2/6.  ABDOMEN:  Soft, nontender. She has distention.  EXTREMITIES:  No edema. Dorsalis pedis pulse is okay in the left side, but weak in the right side.  SKIN:  She has a significant erythema on the genitalia and bilateral medial upper thigh. She has brownish discoloration all over.  CENTRAL NERVOUS SYSTEM:  Grossly intact. MMSE 26/30. GDS was not completed because she refused to answer questions. She has insomnia. 

PHYSICAL EXAMINATION:  GENERAL:  Reveals a pleasant male in no acute distress.  VITAL SIGNS:  Respirations 24, pulse 66, blood pressure 142/72, oxygen saturation 94% on 4 L of nasal oxygen.  SKIN:  Warm and dry. There is mild palmar erythema.  HEENT:  Reveals pupils equal and round with full extraocular movements and visual fields. Fundi were not seen. The nose and throat are clear. External auditory canals are unremarkable. The patient hears finger rubs at 6 inches from the ear in both ears, although there is more difficulty with the right ear than the left.  NECK:  Supple without thyromegaly or mass.  LYMPHATIC:  Unremarkable.  LUNGS:  Lung fields show rales one-third way up both bases. Neck veins are indistinct.  HEART:  S1 and S2 are somewhat diminished with grade 3/6 systolic ejection murmur heard best at the base and extending to the carotids. Carotid upstrokes are slow and weak. Other pulses are trace at the brachial and femoral areas, 1+ to the left radial, absent right radial, and not palpable at dorsalis pedis and posterior tibialis. There are no carotid, femoral, abdominal, flank, or back bruits. The systolic murmur radiates somewhat to the carotids.  ABDOMEN:  Mildly protuberant and soft with healed surgical scars. The liver edge is palpable at one fingerbreadth below the right costal margin, somewhat firm, and nonpulsatile. There is no HJR. Bowel sounds are active and there is no tenderness or mass otherwise. There is no CVA tenderness. There are no abdominal, flank, or back bruits.  EXTERNAL GENITALIA:  Normal.  RECTAL:  Deferred.  EXTREMITIES:  Show no edema or tophi.  NEUROLOGIC:  Cranial nerves III through XII are normal, strength is 5-/5 symmetrically throughout, and sensation is normal to light touch. Deep tendon reflexes are absent. Plantar reflexes show no response. There is no tremor, asterixis, or pronator drift. The finger-nose maneuver is normal. 

PE Sample # 3          

PHYSICAL EXAMINATION:  GENERAL:  Reveals a pleasant female in no acute distress, fatigued and mildly sedated.  VITAL SIGNS:  Temperature 99.2, respirations 18, pulse 68, blood pressure 152/72, and oxygen saturation 99%.  SKIN:  Warm and dry.  HEENT:  Reveals pupils equal and round with full extraocular movements and visual fields. The nose and throat are clear and external auditory canals are normal.  NECK:  Supple without thyromegaly or mass evident, and there is a left internal jugular central venous catheter in place as well as a surgical incision at the base of the throat, which is dressed and a Jackson-Pratt drain is also evident in the area. There was a left anterior chest wall wound, which is dressed.  LUNGS:  Lung fields are clear. Neck veins are one-third. HEART:  The S1 and S2 are normal without rub or gallops. A 2/6 systolic ejection murmur. Pulses are 2+/4 in the carotid, brachial, right radial, femoral, dorsalis pedis, posterior tibialis. There are no carotid, femoral, abdominal, flank or back bruits. The left radial pulse was absent, and a left upper arm simple fistula was patent and clear. ABDOMEN:  Soft and nontender with active bowel sounds and no mass or organomegaly evident. EXTREMITIES:  Showed no edema. The right forearm shows a dressed wound. There is no edema. NEUROLOGIC:  Reveals cranial nerves III through XII to be normal, strength is 5/5 throughout, and sensation is normal to light touch. Deep tendon reflexes are absent. Plantar reflexes showed no response. There is no Chvostek sign.

PHYSICAL EXAMINATION:  Showed the patient to have 3+ edema and 1+ ecchymosis to the left upper and lower lids. The visual acuity and confrontation to visual acuity could not be measured, as a retrobulbar block had been delivered. Extraocular muscles could not be evaluated for the same reason. The pupil was dilated pharmacologically for the procedure. The ballottement of the globe revealed 3+ orbital pressure noted; however, the ballottement was thought to reveal a globe with a pressure of 30 to 40 mmHg. This was different than the Tono-Pen measured with the lid speculum in. It was likely that the retraction with the lid speculum increased intraocular pressure in this circumstance. With careful retraction of the upper lid and both surgeons working together, the intraocular pressure was measured at 42. A repeat measurement was 39. A repeat measurement was 37 with trending of decrease. The globe was palpated by both surgeons and agreement was that the pressure was in the range where the problem could be managed medically. The patient then received topical intravenous therapy, and lateral canthotomy and cantholysis was deferred. Was noted to have a more benign exam by the report of the vitreoretinal surgeon 1 hour following this incident.

PHYSICAL EXAMINATION:  The patient is bright and alert.  She has a pleasant disposition.  Her anterior fontanelle is soft, flat and pulsatile.  There is mild right parietal swelling.  Otherwise, there is no evidence of raccoon eyes, no Battle sign.  There are cranial bruits.  A normal red reflex was seen and I do not appreciate any obvious retinal hemorrhages and the tympanic membranes are clear.  Neck is supple and nontender.  The infant has normal facial movement and there is no asymmetry. The extraocular movements are full.  The pupils were 3 mm and reactive.  I did not appreciate any focal motor, sensory, or reflex abnormalities.  Developmentally, the patient appears appropriate for age.

PHYSICAL EXAMINATION:  General:  He is a pleasant gentleman in no distress.  He is alert and oriented x3.  Affect is normal.  Appearance is normal.  Heart rate is regular and 74 beats per minute.  Respiratory rate is 16.  Blood pressure is 126/82. Skin:  Clear.  HEENT:  Reveals he is normocephalic and atraumatic.  Pupils, sclerae, and conjunctivae are all clear.  Chest reveals no rales, wheezes or rhonchi.  Heart  exam reveals no JVD.  Carotid impulses are 1+ and equal without bruits or thyromegaly.  Auscultation reveals a regular rate and rhythm with normal S1 and S2.  There are no murmurs, rubs or gallops.  No thrills or heaves.  PMI is not enlarged and nondisplaced.  Distal pulses are 1+ and equal.  There is no pitting edema, clubbing or cyanosis.  Bowel sounds are active.  Neurologic exam is grossly intact.

PHYSICAL EXAMINATION:  The patient is a well-developed, well-nourished female, who appears to be in no acute distress.  Blood pressure 102/62 with nitroglycerin paste on, down from 172/94 on admission, heart rate 66 and regular.  HEENT:  Head is normocephalic.  Neck:  Soft and supple.  Thyroid is midline and nonnodular.  No carotid bruits noted on auscultation.  Respiratory:  The patient does have inspiratory/expiratory wheezing throughout.  Her respirations, however, are quiet and unlabored.  She has bilaterally equal excursion.  Cardiac:  Heart is rhythmic and regular without any murmurs, gallops or rubs.  There is no jugular venous distension.  No hepatojugular reflexes and the PMI is nondisplaced; it is in fifth intercostal space, midclavicular line.  There is trace pitting edema of the left leg with none in the right.  Abdomen:  Soft and nontender.  Bowel sounds are present throughout.  Musculoskeletal:  The patient has no unilateral muscle wasting.  No joint effusions or erythema.  Neurological:  The patient is alert and oriented with no focal neurological deficits noted on inspection.

PHYSICAL EXAMINATION:  He is awake, responsive, and in no acute distress.  Vital signs:  Blood pressure 104/62, pulse is 88, and temperature is 98.5.  HEENT:  Pupils round and reactive.  Sclerae anicteric.  Neck is supple without JVD, goiter or carotid artery bruit.  Heart:  S1 and S2.  No murmurs or gallops.  PMI is in normal position.  Lungs:  Good breath sounds with few rhonchi, but no wheezes.  Tactile fremitus is normal.  Abdomen is soft and nontender.  No organomegaly.  Extremities: No edema or clubbing.  Skin:  Warm.  No rash.  Pulses are palpable and equal bilaterally.  Lymph Nodes:  Not palpable in the neck, supraclavicular or axillary area.  Neurologic:  Nonfocal.  Cranial nerves are intact.  No sensory deficits.

PHYSICAL EXAMINATION:  VITAL SIGNS: Temperature 97.8, blood pressure 158/100, pulse 74, respiratory rate 18, oxygen saturation 95% on room air. GENERAL:  This is a well-developed male who is alert and oriented x3 in no apparent distress. HEENT: Normocephalic, atraumatic in reference to the cranium. There is a small laceration over the right zygomatic arch, approximately 3 cm in width. The orbits are intact. Pupils equal, round, reactive to light. There is no instability of any of the facial bones. Tympanic membranes are clear, without hemotympanum, and there is no septal hematoma. NECK: Supple without lymphadenopathy. CHEST: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, nontender, nondistended. MUSCULOSKELETAL: No clubbing, cyanosis or edema and there is no tenderness to palpation over the cervical, thoracic or lumbar spines. There is also no tenderness to palpation over the ribs, clavicles, scapula or the extremities. SKIN: Reveals no other lesions or rashes. NEUROMUSCULAR: Cranial nerves II through XII are intact. Sensation is intact bilaterally in the upper and lower extremities. Visual fields are full. Strength is 5/5 bilaterally, upper and lower extremities. Finger-to-nose and heel-to-shin testing were performed without difficulty. The patient's gait is observed to be normal. 

PHYSICAL EXAMINATION:  VITAL SIGNS: Blood pressure is 143/82, temperature is 97.4, pulse 131, and respirations 18. GENERAL: The patient is in no acute distress, A&O x3. SKIN: Natural in color. Capillary refill is brisk. HEENT: Unremarkable. NECK: No cervical tenderness. Full range of motion of the C-spine. CARDIAC: Regular rate and rhythm. LUNGS: Clear to auscultation in all lung fields. ABDOMEN: Soft and nontender. MUSCULOSKELETAL: Left lower extremity reveals good strong dorsalis pedis and poster tibialis pulse. The patient's left hip, knee, and ankle are nontender. Left calf soft and nontender. Intact Achilles tendon. Left foot examination reveals point tenderness with palpation over the left fourth and fifth metatarsal bases. There is some mild soft tissue swelling and ecchymosis noted at this area. The patient is able to plantarflex and dorsiflex the left foot. Good full range of motion of digits 1 through 5 of left foot. Weightbearing is limited secondary to pain.