NEUROLOGIC EXAM: Neurologically, he is intact, moving all 4 extremities symmetrically and spontaneously with full motor strength. He has normal sensation to light touch.

NEUROLOGIC: No acute neurologic changes are noted. Again, his orientation and judgment demonstrates confusion.

NEUROLOGIC: Spontaneous eye opening, nonverbal. He has some decorticate positioning and some spasticity of the upper extremities.

NEUROLOGIC: She is alert, consolable after exam and appears nontoxic.

NEUROLOGIC: She is oriented x3. Cranial nerves are intact, 5/5 grip strength.

NEUROLOGIC EXAM: He is somnolent, arouses to verbal stimuli. He answers 1 question at a time and drifts back to sleep. Cranial nerves are otherwise intact. He has 4+/5 grip strength and equal bilaterally.

NEUROLOGIC: She is oriented x3. Cranial nerves II-XII are intact.

NEUROLOGIC: He has 2/4 reflexes at the knees bilaterally, 1+/4 reflexes at the ankles and equal bilaterally. He is able to stand on heels and toes.

NEUROLOGIC: She is alert with a social smile, following simple commands. She has a normal gait.

NEUROLOGIC EXAM: 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. 5/5 strength in upper and lower extremities bilaterally.

NEUROLOGIC: GCS is 15. Cranial nerves II through XII are grossly intact. Strength is 5/5 throughout. No sensation difficulties are noted. No evidence of ataxia.

NEUROLOGIC EXAM: She is moving all 4 extremities spontaneously and equally. No weakness, numbness or tingling is appreciated. She has equal bilateral grip strength. Reflexes are 2+ and symmetric bilaterally, upper and lower extremities. Finger-nose-finger and Romberg testing is normal. No evidence of ataxia. Gait is normal, non wide-based.

NEUROLOGIC EXAM: Do not appreciate any frank deficits. The patient is somewhat noncooperative, and she seems to be altering her physical exam. Cranial nerves II-XII appear to be intact; however, she does not want to cooperate with extraocular muscle movements. I asked her to stick out her tongue and she initially sticks it straight out and then moves it to the left. I then asked her to smile and she smiles normally, but then sort of moves the right side of her lower lip off to the side, and I can actually see the muscles of her face contracting to make this grimace and make her smile asymmetric. Also, she will hardly comply with strength testing in her upper extremities but was able to use her bilateral upper extremities to grab the rails on her bed and pushed herself up from a lying to a sitting position. She was able to lift her own weight essentially up off the bed without difficulty, but then when I asked to test her strength, she acted as if she could barely lift her arms up off the bed. Her DTRs are symmetric and intact to the upper and lower extremities. She has a normal Babinski reflex with toes downgoing bilaterally. Her sensation is grossly intact throughout, and she is able to move all 4 extremities, and she ambulated to and from the bathroom without difficulty.

NEUROLOGIC: He has no focal deficits. Cranial nerves II through XII are grossly intact. Sensation is intact throughout. He is moving all 4 extremities. Follows complex commands. DTRs are symmetric and intact in upper and lower extremities. Strength is symmetric and intact throughout, and he has no pronator drift. Equal and symmetric finger-to-nose coordination. He is able to walk with an uneven steady gait; however, when you ask him to turn around, he does seem to be just a little bit off balance, and he gets extremely off balance with heel-to-toe walking. He is able to a heel-to-shin test bilaterally without difficulty and has a negative and normal Romberg testing.

NEUROLOGIC EXAM: She has no focal neurologic deficits. Cranial nerves II through XII are grossly intact. Sensation is intact throughout. She is moving all 4 extremities. Follows complex commands. She has no pronator drift. Equal and symmetric finger-to-nose coordination. Strength is +5/5, symmetric and intact. DTRs are symmetric and intact to the upper and lower extremities. I did administer portions of mini-mental status exam, and she can tell me her name, her daughter’s name, where she is. She gets a little confused on the day of the week, but she states that is typical for her, and she is able to tell me the year and who the president is. She is completely unable to do serial 7s, cannot even begin to tell me 100-7 and is able to spell “world” forward but did not spell it backwards at all. In fact, gives me numerals when she tries to spell it backward. However, she is not having any word finding difficulties, is completely appropriate with clear speech.

NEUROLOGIC: GCS of 15. Cranial nerves II through XII grossly intact. He has normal strength in upper and lower extremities. He has no pronator drift. Normal finger-to-nose. Normal rapid alternating movements. Negative Romberg and normal gait.

NEUROLOGIC: No gross motor sensory deficits. The patient is alert, cooperative and exhibits intact distal sensation in all digits of left foot.

NEUROLOGIC EXAM: Alert and oriented x3, normal mental status. Cranial nerves II-XII intact. Strength 5/5 bilaterally throughout. There is no pronator drift. Subjectively, the patient does have decreased sensation to light touch in the right upper and right lower extremity as compared with the left; however, objectively, her sensation is intact to light touch. Deep tendon reflexes 2+ bilaterally. Station and gait within normal limits. Negative Romberg sign. No cerebellar signs.

NEUROLOGIC: A&O x4. GCS 15. He has 5/5 strength throughout. Normal gross sensation throughout. 2+ deep tendon reflexes in patellar tendons and biceps tendons bilaterally.

NEUROLOGIC EXAM: A&O x4, 5/5 strength throughout. Normal gait. No dysarthria, no dysmetria, no pronator drift. 2+ deep tendon reflexes in patellar tendons and biceps tendons bilaterally.

NEUROLOGIC: The patient is alert and oriented x3. The patient’s gross sensation to touch intact. Cranial II-XII grossly intact. Tandem gait is normal. Heel-to-toe is normal.

NEUROLOGIC: He is neurologically intact to gross touch and sharp and dull. The patient is awake, alert and oriented x3. The patient has 5/5 strength in all extremities.

NEUROLOGIC EXAM: Cranial nerves II-XII grossly intact. Strength is 5/5 throughout. Sensation is intact and symmetric. Gait is normal. Romberg is negative. Cerebellar function tests are appropriate and symmetric. He is able to ambulate on his toes. He is able to ambulate on his heels. He has no saddle anesthesia. Straight leg raise reproduces his pain on the right side. Straight leg raise on his left leg does not reproduce the pain.

NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves II through XII are intact except for left central 7th nerve paresis, left homonymous hemianopsia. Sensation was decreased in stocking-glove fashion in the extremities. Babinski was positive on the left. Deep tendon reflexes were exaggerated on the left. Sitting balance was good. Standing balance was impaired.

NEUROLOGIC: Cranial nerves I-XII grossly intact. Cerebellar function of finger-to-nose and toe-to-toe walking is WNL. Strength is 4+ throughout on all 4 extremities.

NEUROLOGIC EXAM: She is alert and oriented in all 3 spheres. Normal speech and language function. Memory is intact in all modalities. Pupils are 3 mm, round, and reactive to light and accommodation. No visual field deficits. Extraocular movements are full. No nystagmus. No facial asymmetry. Auditory canals are intact. Muscle bulk and tone are within normal limits. No evidence of any focal motor or sensory deficits. Intact deep tendon reflexes. Plantar response is downgoing bilaterally. Finger-to-nose test did not show any ataxia. Gait is not tested at this time.

NEUROLOGIC: He is alert and oriented, able to follow 3-step commands. Cranial nerves II through XII are grossly intact. Sensation is patchy in the lower extremities. The patient did have proprioception in the greater toe on the left lower extremity but absent on the right, and bulbocavernosus reflex was absent. The patient had no reflexes in the lower extremities. Reflexes were present in the upper extremities.

NEUROLOGIC EXAM: Mental status as above. The patient is able to point to his right hand. Graphesthesia and stereognosis was not tested. Light touch was not tested. Motor exam: Essentially right dense hemiparesis with only trace adduction at the shoulder and hip on the right side, left side is within normal limits. The right upper extremity is flaccid. Reflexes are diminished in the right upper extremity; in the right lower extremity, toes are upgoing. Tone is essentially flaccid as well, and reflexes are unable to be obtained at the knee.

NEUROLOGIC: Awake, alert, articulate, oriented x3. Cranial nerves II through XII are intact. Motor and sensory are equal and intact. Toes are downgoing. Heel-to-shin and finger-to-nose are completely normal.

NEUROLOGIC EXAM: Alert and oriented x3. Speech was a little bit slurred, but his mentation was intact. His motor and sensory were intact. His gait was steady.

NEUROLOGIC: Oriented x3. Normal gait. No muscle atrophy or tremor. Cranial nerves II through XII are intact. Normal strength, sensation and coordination. Babinski is downward. No focal motor or sensory deficits. DTRs 2/4.

NEUROLOGIC: The patient has negative Tinel, negative Valleix, negative clonus, negative Babinski. The patient does have diminished 5.0 Semmes-Weinstein filament over the fifth metatarsal head to the right. The patient has long, thick dystrophic toenails, tender upon palpation. Skin inflamed, especially under the nail bed of fourth toe to the left. Nails are roughly 6 to 8 mm in thickness. Nails are yellow, dystrophic, crumbly, resembling onychomycosis.

NEUROLOGIC EXAM: The patient is awake, alert and oriented to time, place and person. Could tell year, month, and name of the president and no aphasia or dysarthria. Cranial nerve exam shows pupils are reactive. Disks are sharp. Visual fields are full. Extraocular movements are normal. Face is symmetrical. Tongue is midline. Gag is intact. Sternomastoid and trapezius are normal. Motor system exam reveals normal tone and strength in upper and lower extremities. Deep tendon reflexes are +2 at the biceps, +2 at the triceps, +2 at knees. Plantars are flexor. No sensory signs. Cerebellar exam reveals finger-to-finger and finger-to-nose intact; however, the patient was severely ataxic on sitting.

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EXTREMITIES: Examination of his wrist joint is stable. Dorsally, on the radial side, he has some swelling and tenderness. There is no snuffbox tenderness or tenderness in the palm. The rest of his metatarsals and phalanges are normal and nontender. Capillary refill is brisk.

EXTREMITIES: Pedal pulses are absent, 1+ ankle edema bilaterally.

EXTREMITIES: No edema, no varicose veins.

EXTREMITIES: Warm, nonedematous. No obvious deformity.

EXTREMITIES: Right wrist: He reports very mild tenderness with flexion, but really, there is no point tenderness. His entire hand is nontender. His elbow is uninjured. Left knee: He has an abrasion anteriorly. Joint is stable, and he can flex and extend against resistance. Distally, he is neurovascularly intact.

EXTREMITIES: No clubbing, cyanosis or edema.

EXTREMITIES: There is no edema. He has good cap refill and distal pulses.

EXTREMITIES: There are no appreciable deformities or swelling. The patient has had some tenderness to palpation, primarily on the dorsum of the left foot. Otherwise, there is no lateral malleolar tenderness to palpation. There is no base of the fifth metatarsal tenderness to palpation. There is no proximal fibular or tibial tenderness to palpation.

EXTREMITIES: The patient has some swelling on the ulnar aspect of the left wrist as well as over the area of his hypothenar eminence. He has some nonspecific tenderness to palpation over the ulnar aspect of the left wrist dorsally. He has no metacarpal tenderness. He has limited range of motion secondary to pain at the left wrist. He has good capillary refill otherwise.

EXTREMITIES: No edema. There is good cap refill. There is no long bone tenderness or tenderness to palpation of the clavicles, humerus, forearm, femur, knees, tibia, fibula or ankle bilaterally.

EXTREMITIES: There is no edema. The patient is noted to have approximately a 4 cm laceration on the volar aspect of the left ring finger. Radial, ulnar and median nerves are intact. She has good two-point discrimination. She has good cap refill and distal pulses.

EXTREMITIES: She does have some tenderness to palpation in the proximal phalanx of her left fourth digit. She does have good range of motion at the MCP and PIP. There is no bruising. Minimal swelling is noted. She has only minimal tenderness. There are no lacerations.

EXTREMITIES: The patient has multiple puncture wounds to the left thumb area in the thenar mass. She has full range of motion of the thumb. She has full range of motion of all digits in her hand. She has no evidence of an early cellulitis. Right hand: She has a small laceration to the middle phalanx of the right hand. It is superficial in nature. She also has a puncture wounds proximally. She once again has good range of motion in all digits. She has good sensation. There is minimal amount of swelling at the right proximal phalanx on the third digit.

EXTREMITIES: He does have swelling in his right upper extremity between the area of the elbow and the wrist. He has some erythema. He does have a hardened area just distal to the antecubital area. He has good range of motion in his elbow. Good range motion in his wrist and his radial, ulnar, and median nerves were checked for motor function and all within normal limits.

EXTREMITIES: No clubbing, cyanosis or edema. She does have some tenderness to palpation over the right trapezius area. She has full range of motion of her right and left shoulders. She does have full range of motion of her neck.

EXTREMITIES: Significantly decreased range of motion in the right wrist secondary to pain. Passive range of motion is appropriate. Tenderness to palpation along the posterior aspect of the distal radius and ulna with some local edema. No evidence of any gross bony abnormality. On exam, he is able to move all fingers in all directions and does have good capillary refill in all fingers.

EXTREMITIES: Minimal discomfort to the muscles of the paraspinous of the lumbar paraspinous area. He does have positive straight leg raise on the left. He has no tenderness along the midline of the lumbar or thoracic spine. He has no rashes in the area as well.

EXTREMITIES: Left knee has a good amount of joint effusion. He has certainly decreased range of flexion. He can only flex to about 35 degrees. He has point tenderness both lateral and medial to the knee. He does not seem to have a joint instability.

EXTREMITIES: Exam was normal with the exception of pitting edema in the lower extremities.

EXTREMITIES: The patient had no edema. The patient had 2+ DP pulses bilaterally and overgrown toenails but no signs of infection.

EXTREMITIES: Good range of motion at the right knee. There was an area of drainage from the anterior knee that had purulent material coming from it. There was good range of motion of knee.

EXTREMITIES: Normal range of motion of the right hip, ankle, and the digits on the right foot. He complains of pain with extreme flexion and extension of the right knee, has some slight soft tissue swelling and faint ecchymosis along the lower medial aspect of the right knee. Anterior drawer sign was negative. His medial and lateral collateral ligaments appear stable. Sensation is intact. Capillary refill is less than 2 seconds. Distal pulses are intact.

EXTREMITIES: No clubbing, cyanosis or edema. No Homans or palpable cords.

EXTREMITIES: Right lower extremity examination reveals no hip tenderness, no femur tenderness. There is slight swelling to the knee area. There is no joint instability. There is a positive Lachman’s and negative McMurray’s. There is medial joint line tenderness. There is no anterior or posterior drawer sign of any significance. There is no crepitation. There is slight soft tissue tenderness over the infrapatellar region. Distal neurovascular as well as tendon status intact. There is no other bony soft tissue tenderness to entire right lower extremity.

EXTREMITIES: No abnormality to the shoulders, including no sergeant’s patch. There is full range of motion. There is no bony tenderness. There is no step-off or obvious deformity.

EXTREMITIES: Examination of right and left wrists reveals tenderness and a soft tissue area over the dorsum of the carpal regions. There is no scaphoid tenderness. There is a negative Finkelstein’s test. There is no tenderness with range of motion, no obvious swelling. Distal neurovascular as well as tendon status intact. No other bony soft tissue tenderness.

EXTREMITIES: Right hand examination reveals swelling over the dorsal aspect of the hand at around the third and a little bit of the second metacarpal and metacarpophalangeal joint region. There is noted tenderness along this region. There is no other bony soft tissue tenderness along the entire right hand or wrist region. There is no rotational deformity. Distal neurovascular as well as tendon status intact. There is no crepitation, no increase in warmth or erythema.

EXTREMITIES: He has fairly lax extremities, arms and legs. No significant posturing noted at the present time. His family notes that he has had some plantarflexion in his legs and tone in his legs, but this is not apparent on my examination today. He has pneumatic compression boots in place as well as egg-crate waffle boots at both ankles, and I am able to get him through a full range of motion in his lower limbs and upper limbs.

EXTREMITIES: He does have a Bledsoe brace present on his left foot. He has scars on the lateral aspects of both thighs, which are well approximated and sutures are removed. There is only a bit of discharge from a lateral malleolar punctate wound, and this appears to be more serous than anything concerning.

EXTREMITIES: Distal pulses are 2+, and capillary refill is brisk. The patient has no discrete long bone tenderness or deformity. She does have some vague pain around the right shoulder; although, she has full range of motion both passively and actively, and there is no discrete bony tenderness at either the AC joint or the humerus itself. On the right lower extremity, the patient has full range of motion passively and actively to the right hip without any discrete tenderness over the groin or greater trochanter itself.

EXTREMITIES: No cyanosis, edema or clubbing. She has mild tenderness with palpation to the medial and lateral left malleolus with no gross deformity, ecchymosis or swelling. DP and PT pulses are present and equal bilaterally with brisk capillary refill in all 5 digits. She has full range of motion of the left foot and ankle and full strength with resisted movement. There is no ligamentous laxity. Thompson test is negative. The remaining extremities show no evidence of trauma.

EXTREMITIES: The patient does have a splint intact to her left lower extremity. There is brisk capillary refill in the toes, and she does have good range of motion of the toes as well as feeling at this site. There is no drainage on the wounds themselves. No lymphangitic streaking, no surround evidence of cellulitis. There is some mild edema to this lower extremity consistent with postoperative edema as well as diffuse point tenderness all about the leg.

EXTREMITIES: The patient does have an AFO plastic molded splint intact to the left lower extremity as well as some mild diffuse tenderness about both the left shoulder and knee without any focal point tenderness. She has good range of motion of all of her extremities and good capillary refill.

EXTREMITIES: Focused examination of the right lower extremity exhibits no gross deformity, ecchymosis or swelling. There is no erythema or warmth to palpation to the knee. No evidence of effusion. There is no laxity with varus or valgus stress. Anterior and posterior drawer tests are negative. Thompson’s test is negative. The patient has diffuse tenderness noted throughout. She has full range of motion with increased pain on extreme flexion. The hip and knee are unremarkable. The remainder of extremity is otherwise unremarkable.

EXTREMITIES: Focused examination of the left hand exhibits no gross deformity, ecchymosis or swelling. The patient has packing placed in wound at the distal pad of the third finger. There is no erythema or warmth to palpation, no tenderness to palpation. Once the packing was removed, there was no purulence that could be expressed. No induration or fluctuance appreciated. This appears to be healing well. Radial and ulnar pulses are present and equal bilaterally with brisk capillary refill in all 5 digits. Sensation is intact to light touch and pinprick in all 5 digits. He has full range of motion and full strength with resisted movement in all 5 digits, including the third finger of the DIP, PIP and MCP joints. Axillary, median, radial and ulnar nerves are intact. He has multiple calluses on his hand.

EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis and no edema.

EXTREMITIES: The patient does have a first-degree burn noted to the dorsum of the right forearm. There is no blistering noted. There is some redness noted. The burn is approximately 5 x 3 cm across. The patient has 2+ radial pulse of the right upper extremity, 5/5 strength of the right upper extremity. Full range of motion of right upper extremity.

EXTREMITIES: Left hand examination reveals an unroofed blister over the proximal phalanx of the middle finger. He has some slight redness and swelling of this area of the middle finger. There is no drainage or purulent material. The hand is neurovascularly intact as far sensation and range of motion. There is erythema also of the proximal aspect of the left third finger.

EXTREMITIES: Peripheral pulses x4 are appropriate, equal and symmetric. An arterial venous shunt is noted in the left upper extremity with good thrill.

EXTREMITIES: Left shoulder without any soft tissue swelling. Range of motion is normal. Left upper extremity has the PICC line, and there is no obvious edema of the arm. Extremities are warm. There is no peripheral edema. There is some atrophy of the musculature of the lower portion of the legs secondary to polio. He does have a boot present on his left foot. There are no obvious venous cords. There is no calf tenderness.

EXTREMITIES: Left upper extremity is notable for an AV fistula with a positive thrill and bruit.

EXTREMITIES: There is no cyanosis or edema, strong radial pulses bilaterally. She has 5/5 strength. Sensation intact. Deep tendon reflexes 1+ equal and good radial pulse. Sensation is grossly intact.

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ABDOMEN: Normoactive bowel sounds. Soft, nontender, nondistended. No masses. No hepatosplenomegaly.

ABDOMEN: Soft, nondistended, positive bowel sounds. Nontender in all 4 quadrants. No pulsatile mass.

ABDOMEN: Soft and nondistended. Positive bowel sounds. Tenderness in the right upper quadrant. No mass noted. No rebound or guarding. Negative Murphy sign. No tenderness in the lower quadrant of the abdomen.

ABDOMEN: Soft, nondistended, positive bowel sounds. Completely nontender in all 4 quadrants except for some upper abdominal tenderness that appeared to correlate with the lateral aspects of the rectus abdominis muscle. There is no tenderness around McBurney’s point or anywhere below the umbilicus.

ABDOMINAL EXAM: Soft, positive bowel sounds. Diffusely tender. There is no rebound or rigidity. There is no pulsatile mass, no abdominal bruit. No Cullen’s or Grey-Turner’s sign. No CVA tenderness.

ABDOMEN: Soft, positive bowel sounds, slight tenderness in the epigastrium. Noted tenderness of a Murphy’s sign in the right upper quadrant without rebound or rigidity. No pulsatile mass, no abdominal bruit, equal femoral pulses. Nondistended.

ABDOMEN: Soft with some mild suprapubic tenderness to palpation without rebound or guarding.

ABDOMINAL EXAM: Soft, nontender, nondistended. He has a G-tube that is in place. There is no leakage around the G-tube site. There is no evidence of cellulitis. He does seem to have stool throughout his abdomen just by palpation.

ABDOMEN: Soft. He does have some tenderness to palpation in his left lower quadrant into the inguinal area with no rebound tenderness, no guarding. Rest of his abdominal exam is nontender to palpation. He has no organomegaly.

ABDOMEN: Soft with palpation. She really did not have any tenderness to palpation along the abdomen. Her pain was primarily along the lower edge of the sternum and along the xiphoid as well as just to the left along the rib in this area. There was no obvious skin trauma. She denied any pain to palpation with compression of the ribs on the sides.

ABDOMINAL EXAM: Soft without tenderness, lymphadenopathy or masses. There is no upper abdominal organomegaly; however, mass can easily be appreciated arising approximately 6 cm above the superior aspect of the mons pubis. It lies in the midline and the component that can be appreciated abdominally measures approximately 10 x 8 cm.

ABDOMEN: Soft, nondistended. Minimally tender to palpation to the suprapubic region without guarding, rebound or peritoneal signs. Good bowel sounds throughout. No CVA tenderness bilaterally.

ABDOMINAL EXAM: Soft and obese, tender to palpation to the right upper quadrant without guarding, rebound or peritoneal signs. Secondary to body habitus, it is difficult to appreciate if she has any sort of organomegaly, but there are good bowel sounds present throughout. No CVA tenderness bilaterally.

ABDOMEN: Soft, obese. The patient is noted to have an area of cellulitis on the mid lower pannus that is probably about 12 x 8 cm with a central, what appears to be blister or vesicle with some serous and slightly purulent fluid draining from it. There is no evidence for frank abscess at this point or underlying fluctuance. There is about 2 cm in diameter of underlying induration beneath this vesicle that has ruptured on its own. There is no lymphangitic streaking, no inguinal lymphadenopathy associated. His abdomen is, for the most part, nontender with good bowel sounds and no CVA tenderness. The skin is otherwise intact.

ABDOMINAL EXAM: Gravid. Fundal height 37 cm. Estimated fetal weight 6 pounds 8 ounces.

ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. A scar from his previous appendix surgery was noted.

ABDOMEN: Soft with diffuse subjective generalized tenderness, nondistended with positive bowel sounds.

ABDOMINAL EXAM: Soft, moderately tender over the suprapubic area. Otherwise, nondistended. There is no palpable evidence of mass, pulsatile or otherwise, as well as any evidence of visceromegaly. He exhibits no rebound tenderness or guarding. He exhibits no CVA tenderness bilaterally. He has normoactive bowel sounds.

ABDOMEN: Soft, moderately tender in the right flank and right costovertebral angle. He is otherwise nondistended. There is no palpable evidence of mass or visceromegaly. He exhibits no rebound tenderness or guarding. He exhibits right CVA tenderness. He has normoactive bowel sounds.

ABDOMEN: Soft, tender in the suprapubic region. He states that his abdomen is distended, but it is soft. No ascites. He has positive bowel sounds in all 4 quadrants. There is no guarding, no rebound. There are no masses or organomegaly. No bruits appreciated. The patient has flank pain bilaterally with percussion, worse on the right than the left.

ABDOMINAL EXAM: There is slight tenderness in the epigastric region. He had positive bowel sounds all 4 quadrants. No guarding or rebound noted. No bruits appreciated.

ABDOMEN: Protuberant, soft, nontender. No guarding, no rigidity.

ABDOMINAL EXAM: Protuberant and soft with slight tenderness in the right lower quadrant. She states she has had her appendix removed. No guarding or rigidity.

ABDOMEN: The patient has an obese abdomen that is nondistended with positive bowel sounds. It is soft and nondistended. The patient does have some right lower quadrant tenderness just along the inguinal ligament that appears to be tender in the right abdominal wall, though not to deeper palpation. There is no guarding, rebound or organomegaly present. The patient’s aforementioned laparoscopic sites in the inguinal fold do not appear to be grossly infected and are nontender to palpation.

ABDOMINAL EXAM: Soft, nondistended. The patient has normoactive bowel sounds. He has some slight epigastric tenderness, but no rebound, guarding or peritoneal signs. No CVA tenderness. He has no tenderness at McBurney’s point. He has a negative Murphy’s sign.

ABDOMEN: Soft, scaphoid and reproducibly tender in the right lower abdomen with voluntary guarding. No peritoneal signs.

ABDOMINAL EXAM: Hyperactive bowel sounds, nontender.

ABDOMEN: Soft, morbidly obese. Diffusely tender. There is no palpable pulsatile mass; however, the patient’s morbid obesity would likely obscure this.

ABDOMINAL EXAM: There is no abdominal tenderness to light or deep palpation.

ABDOMEN: Soft, nontender, morbidly obese. Surgical incisions are noted. There is a prominent abdominal aortic pulse. There are several areas of induration. There is no active cellulitis and no erythema present.

ABDOMEN: Positive bowel sounds. He does have tenderness in the right flank. This is more flank rather than right CVA. There is certainly no right upper quadrant or McBurney’s point tenderness. Rovsing’s is negative. Abdomen is soft. He does have some guarding over the right flank. There is no tenderness over the left flank or left CVA tenderness.

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HEENT: Eyes: No scleral icterus or xanthelasma. Mouth: No oral pallor or cyanosis.

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.

HEENT: Atraumatic, 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. Tympanic membranes have serous fluid behind both of them, but there is no thickening of the tympanic membrane on either side. She has no opacity. No redness.

HEENT: Eye exam: PERRLA. EOMI. ENT exam: TMs and canals are clear. Throat is minimally erythematous posteriorly. No exudate or trismus. He has no obvious dental abscess. He has no tenderness with percussion. He has numerous teeth, which have been pulled and several, which have dental fillings.

HEENT: Moist mucous membranes. TMs and canals are clear. Throat is without erythema. Tooth #17 is missing. Tooth #18 is severely decayed. There is a piece of gingiva starting to cover the posterior cusp. There is no abscess seen.

HEENT: Eye exam: PERRLA. EOMI. She does have a lateral nystagmus. ENT exam: Slight nasal tenderness. No other facial bony tenderness. No step-offs.

HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. No papilledema or hemorrhages are seen. Moist mucous membranes. Throat is without erythema. There is no trismus. TMs and canals are clear. There are no loose teeth. No facial tenderness. Nasal septum is midline.

HEENT: Eye exam: PERRLA. EOMI. ENT exam: No facial droop. Moist mucous membranes.

HEENT: Moist mucous membranes. TMs: Canals are clear. Anterior fontanelle open and flat. Throat is without erythema.

HEENT: Moist mucous membranes. TMs are occluded with cerumen bilaterally. When removed, the left TM is erythematous with loss of landmarks. Throat is erythematous posteriorly. No exudate or trismus.

HEENT: Nonicteric sclerae. PERRLA. EOMI. No sinus tenderness. Left TM has little loss of landmarks, a little red. Right TM is normal. No pain with movement of the pinna. EACs are normal. No mastoid erythema or swelling. No displacement of the pinna. There is positive anterior chain lymphadenopathy, more on the left than on the right. There is no stridor, no laryngeal crepitus. Oropharynx shows moist mucous membranes with reddened tonsillar pillars with a midline uvula and no tonsillar exudate. There is no stridor, no meningismus.

HEENT: Nonicteric sclerae. PERRLA. EOMI. There is no injection to the left sclera. There is no obvious photophobia in a well-lit room. Fluorescein staining and slit-lamp examination reveals no foreign body. There is no hyphema. Negative Seidel test. There are some scratches over the cornea of the eye, over the pupil and the iris. There is no entropion or ectropion. There is no tilting of any of the eyelashes. Lifting up the eyelids reveals no foreign body.

HEENT: Normocephalic, atraumatic. She is tender with percussion over tooth #15. There is decay present throughout the entire oral cavity. No abscess noted.

HEENT: The patient is noted to have active bleeding present in the left anterior Kiesselbach’s plexus, left side of his nasal septum. There are a few clots present. No right-sided bleeding or clots seen. Posterior pharynx is clear.

HEENT: Nonicteric sclerae. Pupils are equal, round and reactive to light and accommodation. Extraocular muscles are intact. There is a noted left subconjunctival hemorrhage. No hyphema. Bilateral TMs are clear and shows no signs of hemotympanum. There is no septal hematoma. There is a laceration noted on the top of the head on the right. There is one on the bridge of the nose. There is obvious deformity to the nose, which may be chronic. There is a laceration below the left eye and zygoma region without any underlying bony tenderness. There is no maxillary or mandibular instability.

HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. The left ear is clear with no erythema, bulging or retraction of the TM. The right ear has a moderate amount of cerumen in the canal. There is no purulent drainage or bleeding noted. No edema of the canal. The TM cannot be fully visualized, what can be seen appears intact with good light reflex and proper landmarks. There is no tenderness with palpation to the tragus or pinna or with percussion to the mastoid process. Oropharynx exhibits no tonsillar swelling, erythema or exudate. Teeth are in good repair.

HEENT: Normocephalic, atraumatic. Pupils are equal, round, reactive. No nasal discharge, no mid facial trauma. He does have soft tissue swelling and some obvious bruising over the left cheek overlying the zygomatic arch down across the mandible on the left-hand side. His midface is stable. His dentition all appears to be intact. He does have a filling in one of the left upper molars from a root canal that was done last week. There is no intraoral laceration or bleeding. His TMs show no hemotympanum, and his maxilla and mandible are stable to palpation.

HEENT: Pupils were anisocoric and it was unclear as to whether the patient was aware of this. Right pupil was 4 mm and minimally reactive. Left pupil was 3 mm and reactive to light. Oropharynx is moist without erythema or exudate. He had some crusted blood in the nares. No evidence of septal hematoma. He had a small 1 cm laceration on the right occiput, which was hemostatic.

HEENT: The patient has a small crusted area in the right lower lip area, just adjacent to the vermilion border. There is some surrounding edema and erythema. No evidence of any Ludwig’s angina. The floor of the mouth is soft.

HEENT: Normocephalic and atraumatic. PERRLA. EOMI. TMs are intact with good light reflex. The patient does have slight edema noted to the area of the left external nose. The turbinates are not erythematous or edematous. She does have a slight area of edema to her inferior left eyelid. Pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric and not injected. Posterior oropharynx is pink and moist without erythema or exudate. She does have a small lesion noted to the area just superior to her left upper lip. It is a small, round, firm lesion that is most likely a cyst. There is no erythema or edema to the area. There is no purulent drainage. The patient states that the area has been there for approximately 2 years.

HEENT: Normocephalic, atraumatic. PERRLA. EOMI. TMs intact with good light reflex. Posterior oropharynx is erythematous with exudate bilaterally on his tonsils. He does have kissing tonsils that are 4+. There is no asymmetry of the tonsils. The uvula is midline. Soft palate rises symmetrically.

HEENT: Normocephalic, atraumatic. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx is without erythema. Mucosa moist and pink. No sinus tenderness was noted. The patient does have multiple dental caries with partial tooth avulsion and has some slight swelling of his gingiva of the right lower molar area, but there is no fluctuance or abscess palpated. No facial swelling was noted.

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. There is no septal hematoma. No nasal displacement. She does have a superficial 1.5 cm abrasion noted to the bridge of the nose with minimal tenderness to palpation to the bone here. There is no ecchymosis or swelling. No Battle or Raccoon sign. The remaining facial bones are otherwise unremarkable. Mucous membranes are pink and moist.

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 erythema, bulging, retraction of the TMs bilaterally. Oropharynx exhibits no tonsillar swelling, erythema or exudate. There is no tenderness with percussion to the frontal or maxillary sinuses. Facies are symmetrical with no obvious swelling. He has very poor dentition. The molars of the left lower jaw are significantly decayed; however, there is no induration or fluctuance appreciated, very minimal erythema and a significant tenderness to percussion to the teeth. His upper and lower incisors have been extracted. There is no submandibular, sublingual or submental tenderness or swelling. No evidence of abscess. Buccal mucosa is normal.

HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. The patient does have a fleck of a foreign body noted on the cornea of the left eye in the 6 o’clock position, just at the pupil rim. There is minimal conjunctival injection. No lid edema or nodules appreciated. No purulent drainage. No photophobia noted. Mucous membranes are pink and moist. Oropharynx exhibits no tonsillar swelling, erythema or exudate. Ears are clear with no erythema, bulging, retraction of the TMs bilaterally.

HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. The left eye conjunctiva is slightly injected. No evidence of foreign body with gross examination or lid eversion. There is no purulent drainage noted. No lid edema or nodules appreciated. No tenderness to palpation. No photophobia. Under Woods lamp examination and fluorescein stain, there is a very small pinpoint abrasion noted in the 8 o’clock position overlying the medial iris. There is no streaming of fluorescein noted under slit-lamp examination. No evidence of puncture or global rupture. No cells or flare in the anterior chamber. Mucous membranes are pink and moist.

HEENT: The patient does have some facial swelling noted to the right cheek. There is no nasolabial fold swelling noted. No lip swelling noted. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted. The patient does have obvious dental caries noted to tooth #12. He does have some slight erythema and edema noted to the gums surrounding this tooth as well. No fluctuance palpated. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted.

HEENT: The patient has positive edema noted to the lower lip and anterior tongue consistent with angioedema. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx is without erythema or exudate. Mucosa is moist and pink. No sinus tenderness noted. The patient does appear to have some facial swelling noted to the right cheek as well. She also has small cold sores noted in the mucosa of the right lower lip.

HEENT: Head is normocephalic, atraumatic. Pupils are equal round and reactive to light and accommodation. Extraocular movements are intact. The patient has no pain with movement of extraocular muscles. She has no proptosis. The patient has no pain or tenderness around her orbits. She has no swelling around her eyes and no erythema around her eyes. Her face is symmetric. Her oropharynx is clear, and her uvula is midline.

HEENT: He had just some clear rhinorrhea noted. TMs are clear. Oropharynx shows moist mucosa.

HEENT: Nonicteric sclerae. PERRLA. EOMI. There is no septal hematoma, no sublingual hematoma, no malocclusion or malalignment of the teeth. There is slight ecchymotic area underneath the superior lip with a little tear of the frenulum that connects to the buccal and gingival mucosa. There are no loose teeth; although, there is some tenderness on moving, particularly numbers 8, 9 and 7. There is no bony tenderness to the face. No hemotympanum.

HEENT: He has dysconjugate eye gaze, divergent on the left side to lateral gaze. He has asymmetric pupils of 3 mm on the right and 4 on the left. These are minimally responsive to light. He is unable to cooperate with any further aspects of the neurologic examination and does not respond to lid opening.

HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes are moist without lesions.

HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes do show some vomit around the mouth but no lesions appreciated. There are no contusions, abrasions or lacerations about the head or face.

HEENT: The patient has 4 mm to 2 mm bilateral reactive pupils. The right eye is surrounded by a large amount of periorbital swelling and is swollen shut; however, we are able to open without difficulty, and the patient’s extraocular movements are intact underneath and also in the left eye. After everting the lids, there are no foreign bodies present; however, on fluorescein exam, it is noted that there are multiple corneal abrasions bilaterally in the eyes. However, there is a negative Seidel sign, and there does not seem to be any globe injury or globe penetration.

HEENT: Head and scalp are essentially atraumatic. Pupils are equal, round, reactive to light. Extraocular muscle movement is normal. Ears are without hemotympanum. Nose: No gross deformity. No obvious soft tissue swelling. There is no septal hematoma. No blood in the nares. Mouth: Moist membranes. Tongue is normal, although there is a piercing. Dentition is intact and there is no gross instability of either the face or teeth. There is a laceration, which extends through the vermilion border of the upper lip on the left side. This is approximately 1 cm long, and it appears to involve the oral mucosa as well. The lower lip has a laceration with some soft tissue swelling that is about 1 cm long as well; although, this does not cross the vermilion border. I do not appreciate any chipping of his teeth. Right jaw has one point of tenderness. There is no soft tissue swelling. He opens and closes the mandible normally and is able to fully open his mouth. There is no soft tissue swelling of the face.

HEENT: Head is normocephalic and atraumatic. Midface is stable. Extraocular movements are intact. Pupils are 4-2, sluggish bilateral. Mucous membranes are dry. Oropharynx is clear.

HEENT: Pupils are equal and reactive. Conjunctivae are clear. Scalp with some mild erythema noted over the occipital region. No hematoma. Subjective tenderness diffusely to palpation of occipital region. Bilateral tympanic membranes normal. No obvious facial trauma, teeth stable, no malocclusion. She has a decayed left lower molar, which is fractured at the crown. According to the patient, this fracture occurred when she was punched. She had no external facial swelling however.

HEENT: Pupils are equal and reactive. Conjunctivae are clear. Extraocular movements are intact. Tympanic membranes are normal. She had some mild tenderness to palpation over the right posterior auricular node and occipital node. She has some questionable folliculitis along the right occipital scapular area with some tenderness. No drainage.

HEENT: The patient has a 3.5 cm linear laceration just inferior to the hair of the right eyebrow. There is also 3 smaller abrasions noted lateral to that. His pupils are 2-3 mm equal, round and reactive. His head shows no other signs of trauma. His TMs are clear. No hemotympanum.

HEENT: No sinus tenderness. Bilateral TMs are clear. No pain with movement of the pinna. EACs are normal. Pupils are equal, round and reactive to light. Extraocular muscles are intact. There is no facial swelling. No palpable lymphadenopathy. No stridor. Intraoral examination reveals moist mucous membranes. There is fractured first tooth with obvious dental tenderness. No surrounding gingival erythema or fluctuance.

The post HEENT Section Physical Examination Transcription Examples appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

GENERAL / GENERAL APPEARANCE SECTION IN PE:

A&O x3

agitated

ambulatory

Apgar score

blank, staring, expressionless face

cachectic

Cheyne-Stokes breathing

chronological age (younger/older than chronological age)

comatose

conscious

cushingoid

depleted nutritionally

diaphoretic

disheveled

elderly, frail

engages with the examiner without difficulty

engaging appropriately

insight to current problem

language disturbance

intubated and sedated

lucid and follows commands

lying in semi-Fowler position

malaise

mask facies

no acute distress

obtunded

orthostatic changes

postanesthesia drowsiness

slurred speech

The patient appears fatigued.

The patient has slurred speech and abruptness of speech.

The patient is a cachectic male/female.

The patient is a pleasant, cooperative, overweight male/female.

The patient is a well-built elderly/young/middle-aged male/female.

The patient is a well-developed, well-nourished male/female.

The patient is alert, awake, and oriented.

The patient is ill appearing.

The patient is in no acute distress, resting comfortably in bed.

The patient is intubated.

The patient is lethargic, confused.

The patient is malnourished.

The patient is moaning and groaning.

The patient is nontoxic, calm, conversant

The patient is responsive to commands. He is following commands verbally.

The patient is lying on a gurney in the emergency room

undue distress

vocabulary

WDWN (well-developed, well-nourished)

wearing glasses

well hydrated

VITAL SIGNS:

blood pressure

BMI (body mass index).

height

O2 saturation

pulse/heart rate

respirations or respiratory rate

T-max

weight

HEENT: HEAD, EYES, EARS, NOSE, THROAT

afferent pupillary defect

agnathia

allergic salute

alopecia

allergic shiners

alopecia noted

anicteric sclerae

anisocoria

anterior tonsillar pillars are red

aphthae

aphthous ulcers

arcus senilis

AV nicking

Battle’s sign

best-corrected visual acuity

bifid

bifid uvula

bifocals (wears bifocals)

boggy turbinates

buccal mucosa

bulbar conjunctivae

cataracts

cleft palate

cobblestoning

conjunctivae pink

conjunctivitis

cornea clear/cloudy

corneal reflex intact

Cowden disease

crowded oropharynx

Dennie-Morgan lines /Dennie-Morgan fold

dental caries

dental hygiene

dentition

dentures

depressed nasal bridge

deviation of mouth

disk margins well-delineated

disks sharp

dysconjugate gaze

ears have mild cerumen or no cerumen

edentulous

effusion

elongation of soft palate

endotracheal tube

enucleated

EOMI

EOMS full. (EOMS can mean either extraocular movements or extraocular muscles)

ET (endotracheal) tube in place

external auditory canal

extraocular movements intact

extraocular muscles intact

facial droop

facial sensation is intact

flattening of the nasolabial fold

floor of mouth is nontender

fontanel (infant exam)

frontal bossing

funduscopic exam

gag reflex

gingiva

gingival hyperplasia

glaucoma

good cone of light

Guerin fracture

hairy leukoplakia

halitosis

hard palate / soft palate

has pterygium on the eye

head trauma

helix of ear is tender to touch

homonymous hemianopsia

hypopharynx and larynx are normal

impacted molars

isocoria or isocoric

Le Fort fracture

Le Fort I fracture

Le Fort II fracture

Le Fort III fracture

lenticular opacification

leonine facies

Ludwig angina

macrocephaly / microcephaly

macular degeneration

Mallampati grade (pharynx is Mallampati grade 3)

mandibular hypoplasia

mastoid air cell tenderness

maxillary, ethmoid, frontal

micrognathia

midface and mandible are stable

moist mucous membranes

mucosa is boggy

mucosal pallor

mucositis

myringotomy tubes

nares, patent

nasal bridge

nasal flaring

nasal mucosa edematous or nonedematous

nasal passages are crowded

nasal prongs

nasolabial fold flattening

nasopharyngeal trumpet

NC/AT

NG tube or nasogastric tube

no epistaxis or epistaxis seen

no exudates, plaques or lesions

no facial lines

no field cut to gross confrontation

no hemotympanum

no papilledema, AV nicking, hemorrhages or exudates noted

no scleral icterus

no traction on the pinna

normocephalic and atraumatic

OP (oropharynx) clear

oral exam shows slight crowding

orbital, periorbital

oropharynx is clear.

oropharynx is noninjected / oropharynx is injected

palatal movements diminished

periodontal disease

PERRL

PERRLA

pharyngeal hyperemia

pharynx is crowded

pharynx pink and moist

phonation problems

Pierre Robin syndrome

pinna

plethoric facies

poor light reflex

posterior pharynx is without thrush

posterior pharynx without injection

pre or postauricular nodes

puffing of eyelids

punctate exudates on tonsils

pupils are equal, round, and reactive to light and accommodation

raccoon eyes

rapid eye movements (REM)

red reflex

Rinne test

sclerae and conjunctivae are normal

septal deviation

sinuses are nontender to percussion

sinuses

slit-lamp examination

sluggish pupils

sore throat

strabismus

symmetrical vocal cord motion

tongue was protruding with some swelling and akinesia

temporomandibular joint

throat is clear

thrush

TMs shiny and clear

TM has a slight bulge and diffusion of cone of light

tongue congestion

tongue is dry

tongue well-papillated

tonsillar hypertrophy

tonsils (tonsils are 3+ bilaterally)

trichilemmoma

trismus (no trismus)

tympanic membranes

uvula

uvula is nonedematous

uvula moves on phonation

vermilion border

visual acuity is _____ (dictated value, usually 20/20)

visual field testing

wax impaction

Weber test

NECK:

anterior cervical lymphadenopathy

bilateral bruits conducted from the aortic areas to both carotids.

Brudzinski sign

carotids are +2/4

carotids are full

elevated JVP up to the angle of the jaw

free of masses.

goiter

hepatojugular reflux or HJR (abbrev)

JVD at 30 degrees, head up position.

meningeal irritation

meningeal signs

meningismus

neck brace.

neck collar.

neck is supple.

no bruits. No carotid bruits.

no cervical or supraclavicular lymph nodes.

no jugular venous distention / No JVD. No JVP. Jugular venous pressure is not raised

no JVD elevation.

no lymphadenopathy or thyromegaly.

no nodularity.

no thyroid enlargement.

nuchal rigidity

nuchal spasm

shotty lymph nodes (sounds “shoddy” but its shotty)

trachea central

trachea midline

tender nodes

venous distention at 45 degrees

HEART OR CARDIOVASCULAR:

A2 louder than P2

apical impulse

apical murmur

audible murmurs

grade 1/6 or 2/6 or 3/6 systolic murmur.

irregularly irregular rhythm

loud P2

loud S3 gallop

no ectopy

no extra heart sounds

no friction rub

no heave or thrill

no MR, no AI

no precordial heave

no S3 or S4 appreciated

pericardial knock

PMI is at the fifth intercostal space.

PMI is at the fourth intercostal space.

PMI is diffuse.

PMI is hyperdynamic.

PMI is not displaced.

PMI.

Point of maximal impulse.

prosthetic click/sound

Regular rate and rhythm.

RRR.

RSR

S1 normal intensity, S2 single.

S1, S2, S3, S4.

S2 snapping sound with mild mitral insufficiency

soft 2/6 or 3/6 or 1/6 systolic murmur along the left sternal border.

soft systolic murmur.

without murmur, gallop, rub or click.

CHEST:

barrel chest

expansion was symmetric

midline sternotomy scar

pigeon chest

LUNGS OR PULMONARY EXAM:

accessory muscles of respiration

adventitious sounds

costophrenic angles

crackles, wheezes, rhonchi.

crepitant rales

CTA (clear to auscultation)

diminished breath sounds.

E to A changes

equal breath sounds

good bilateral air entry.

good breath sounds.

good air exchange

hyperresonant

increased AP diameter

inspiratory, expiratory.

lung fields.

Lungs are clear to A&P.

Lungs are clear to auscultation and percussion.

no retraction

normal AP diameter

pleural rub

unlabored breathing

vesicular breath sounds

ABDOMEN:

all 4 quadrants

appendectomy scar

ascites

ballottable

bowel sounds are active

colostomy is in place

cesarean section/hysterectomy scar seen.

diffuse direct tenderness

epigastric bruit

fluid wave

hyperactive bowel sounds.

hypoactive bowel sounds.

liver and spleen not palpable.

liver is palpable

McBurney’s point

Murphy’s sign

No guarding, rebound, hepatosplenomegaly.

No masses. No hernias.

No organomegaly or masses.

Normoactive bowel sounds.

Obese, bulky.

PEG tube in place.

peristalsis

Positive bowel sounds.

protuberant.

renal angles

scaphoid abdomen

scars from previous surgery seen

scars of surgery.

soft, flat, nontender, nondistended

stoma is patent

Infant / Child Physical Exam Samples

EXTREMITIES OR MUSCULOSKELETAL EXAM:

1+ or 2+ edema.

above-knee amputation

anatomic snuffbox

ankle dorsiflexion

ankle edema.

anterior drawer sign

Apley grind test

Apley’s test

arc of motion

ballotable patella

balls of feet

beats of clonus

below-knee amputation

bilateral symmetrical muscular atrophy

brachial pulses are 1-2+

bunion

calcaneal cuboid

calf tenderness

capillary refill

CCE (cyanosis, clubbing or edema)

Charcot foot.

claudication

clonus

clubfoot.

“clunk” test for tib-fib

Cram test

dependent edema

DJD (degenerative joint disease)

Dorsalis pedis and posterior tibial pulses.

DP and PT pulses.

drop-arm test for rotator cuff tear

DTRs are 2+.

DTRs are brisk.

DTRs are symmetric.

DTRs are trace.

flexion contracture

flexor digitorum

footdrop

functional hallux limitus

genu valgum/genu varum

golfer’s elbow test

good joint range of motion without bony deformities

gravity drawer test

grip is full

hallux valgus

Hawkins test (Hawkins impingement sign)

Heberden’s nodes of osteoarthritis

hip click (infant examination)

Homans sign

Hoover sign / test

Lachman

Ludington test

McMurray’s test

Mild pedal edema / trace pedal edema.

milking the knee

Moves all 4 extremities well.

Mulder sign

Neer test (Neer impingement sign)

neutral calcaneal stance

no bony or joint abnormalities

No calf tenderness.

No cellulitis.

No cyanosis, clubbing or edema.

No lymphedema.

patella apprehension test

peripheral circulation

peripheral pulses are intact

Phalen test

pitting edema.

pivot shift

plantar flexion

poststatic dyskinesia

posterior drawer sign

posterior sag sign

radial pulse

reflexes are 2+ or absent or trace.

resting calcaneal stance

reverse Lasegue test

single leg stance

snuffbox tenderness

Speed test for biceps

stump (in case of amputee patient)

subtalar joint

subungual hematoma

talar tilt test

Thompson test

Tinel sign

toes are downgoing

too-many-toe sign (valgus deformity)

two-beat clonus

valgus/varus

varicose veins.

varus or valgus stress

wide-based gait

Yergason’s test

NEUROLOGICAL:

Alert, awake, and oriented x3.

Alert, awake, and responsive.

anosmia

asterixis

Babinski.

Cerebellar function intact on finger-to-nose and rapid alternating movement

Cranial nerves II through XII grossly intact.

doll’s eye reflex/sign

Dysmetria

extrapyramidal

facial droop

festinating gait

finger-to-nose.

flexors downgoing

Follows simple commands.

foot drop

gait and station

gaze / conjugate gaze / dysconjugate gaze

gaze preference

heel-to-shin.

homonymous field defect

horizontal nystagmus / vertical nystagmus / rotatory nystagmus

hypacusis

intention tremor

Moro’s sign or reflex

motor impairment scale (MIS)

motor power

muscles of mastication

No cranial nerve deficit.

No focal deficits.

No focal weakness.

No headaches or seizures.

No history of convulsion, seizures, TIA or CVA.

noxious stimulation

oculocephalic reflex

oculocephalic maneuver

pronator drift

proprioception

rapid alternating movements

saccadic eye movements

sensory exam – pinprick

straight leg raising positive (negative) at 45 degrees

suck and grasp

tandem walk

two-point proprioception

vibratory sense intact

Withdraws in response to tactile and painful stimuli.

GENITOURINARY/GENITALIA:

balanitis

chancre

chordee

cremasteric reflex

circumcised phallus/penis

condyloma

epididymis

epididymis and cords are normal

Foley to gravity

genital warts

glans is normal

glans penis

meatus is orthotopic, patent and clear

no penile plaques or genital skin lesions

orchiectomy

perineum is normal

Peyronie disease

phallus

prepuce

priapism

scrotal swelling

scrotum

Tanner Developmental Scale

Tanner stage

testes descended bilaterally

testes have horizontal lie

testicular tumor

urethral groove

webbed penis

Physical Exam Words and Phrases

PELVIC:

adnexa negative for mass or tenderness

adnexa nontender

anterior lip of cervix

bimanual exam

bimanual rectovaginal exam

BUS negative. BUS = (Bartholin’s, urethral, Skene’s) glands

cervical motion tenderness

cervix dilated to approximately 2 cm, vertex, -1 station (values given as eg – actual as dictated)

cervix complete, 100% effaced, +2 station (values given as eg – actual as dictated)

cervix 3 cm dilated, 50% effaced, -2 station (values given as eg – actual as dictated)

cervix is long and closed

cervix is posterior and clean

cervix is smooth and normal in size

cervix was high

Chandelier sign

EGBUS – external genitalia (EG), Bartholin, urethral and Skene (BUS)

endometrial curetting

fibroids

GC and chlamydia culture

hysterectomy, oophorectomy

os is closed

pelvic floor

pelvic sidewalls are smooth

specimens for KOH and wet prep

supple pelvic floor

TAHBSO

uterine contour seems to be asymmetric

uterus is anteverted, anteflexed, and regular in contour

uterus is midposition

uterus normal size

uterus normal size, mobile, nontender

uterus retroverted

uterus was anteverted

uterus was sounded at

uterus, tubes, and ovaries

vaginal apex is normal

vagina and cervix without lesions or masses

vagina is pink, moist and rugose

vaginal vault

BREASTS:

no adenopathy

no dominant masses

no gynecomastia (IN CASE OF MALE PHY EXAM)

no nipple discharges or masses

no skin or nipple retractions

symmetrical

RECTAL:

anal wall

abscess

ampulla

black tarry stool

bright red blood per rectum

digital exam

Exam deferred.

fecal occult blood

fissures

fistula, condyloma

heme-positive stools

Hemoccult positive/negative

hemorrhoid

hemorrhoidal plexus

hemorrhoids

normal sphincter tone

prostate

prostate is smooth, nontender and without nodules or fluctuance

rectal ampulla

rectal vault

size, shape, and mobility of prostate gland

stool for guaiac

BACK/SPINE:

kyphoscoliosis

kyphosis

lordosis

No CVA tenderness.

paravertebral

scoliosis

TLSO brace

SKIN:

ABCD – asymmetry, border, color and diameter

angel’s kisses

blanch

branny desquamation

bullae (bulla – singular)

burrows

caput medusae

condyloma

defurfuration

dermatographism

desquamation

eczema

epidermal avulsion

epidermolysis

exophytic lesion

flaking

follicular, horny-spined areas

folliculitis

goatee of face

honeycomb-crusted

hyperkeratotic areas

hyperpigmented plaques

inoculation points

icteric

infiltrative lesion

Janeway lesion

keloid

keratosis, actinic keratosis

Klippel-Trenaunay-Weber syndrome

lesions

lichenification

lymphangitic streaking

lytic lesion

maculopapular exanthem

molluscum

mottled, cyanotic

Muehrcke lines / bands / sign

neoplastic lesion

Nikolsky sign

no lesions, nodules or rashes

no onychomycosis

no streaking

normal color, turgor, and temperature

notable for tattoos

Osler node

papular, pustular rash

petechiae

pink and warm to touch

pitted keratolysis

pityriasis

port-wine stains

pruritic

purpura

purpuric lesions

rosacea

Rhus dermatitis

ruddy complexion

sandpapery rash

satellite lesion

scabies infestation

scale-like rash

scleredema

seborrheic dermatitis

skin cancer

skin tag

skin turgor

sloughing

spider angiomas.

spider nevi

stigmata of liver disease

stork bites

strawberry tongue

tenting

tyloma

ulceration, induration

unbroken and intact

urticaria

vascular streaking

verruca

vesicle

vesicular lesions

vesicular papules

vesiculation

warm and dry without rash

warm, dry, and well perfused

wart

wheal

wheal and flare reaction

xerosis

The post Physical Examination Words and Phrases for Medical Transcriptionists appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

PHYSICAL EXAMINATION:
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.

PHYSICAL EXAMINATION:
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.

PHYSICAL EXAMINATION:
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.

PHYSICAL EXAMINATION:
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.

PHYSICAL EXAMINATION:
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.

PHYSICAL EXAMINATION:
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.

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.

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.

The post Physical Examination Section Words And Transcription Examples For MTs appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

PHYSICAL EXAMINATION: VITAL SIGNS: Weight 6 pounds 7 ounces, length 19 inches, head circumference 13-3/4 inches, and temperature 98.6. GENERAL APPEARANCE: This newborn appears to be a well-nourished, well-developed female.
HEENT: Positive red reflex. TMs clear bilaterally. Nose is clear. Throat is clear. Mouth is intact and clear. NECK: Supple, no thyromegaly. CHEST: Clear to auscultation. HEART: Regular rhythm, no murmurs. ABDOMEN: Soft, no masses, bowel sounds present. EXTREMITIES: Hips: No clicks, no clunks, and no subluxation. Full range of motion. Good femoral pulses, +2 bilaterally. BACK: Normal. SKIN: Normal. NEUROLOGIC: No focal deficits.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 7 pounds 15 ounces. Height 20-1/2 inches. Head circumference 14 inches. GENERAL APPEARANCE: An alert male in no acute distress. SKIN: Pink, no jaundice. HEENT: Red reflexes bilaterally. TMs are normal bilaterally. Throat is negative. NECK: Negative. HEART: Regular rate and rhythm with equal femoral pulses. LUNGS: Clear to auscultation. ABDOMEN: Soft, positive bowel sounds. No distention. The umbilicus is well attached. EXTERNAL GENITALIA: Genitalia show a healing circumcision with descended testes bilaterally and some slight fluid in the scrotum. EXTREMITIES: Hips are negative. NEUROLOGIC: He is alert, vigorous cry, good tone, nonfocal.

PHYSICAL EXAMINATION: VITAL SIGNS: Height 20-1/2 inches, weight 7 pounds 6 ounces, head circumference 14 inches. HEENT: Head is normocephalic. Anterior fontanelle is open and flat. Red-orange reflexes are positive in both eyes. Nose is clear. Mouth is clear. NECK: There is no neck mass. CHEST AND LUNGS: Symmetric. Good air entry and clear breath sounds. HEART: Quiet precordium. Regular rhythm. No murmurs heard. Normal first and second heart sounds. ABDOMEN: Flat, not distended, soft, no mass, no tenderness. The umbilical cord is dry, but still attached.
EXTERNAL GENITALIA: Normal male. Both testes are descended. His circumcised penis has already healed nicely. He has perianal rash and a small amount of stool in his perianal area. SKIN: Generally clear. He has some salmon patches on his forehead, on his nape, and on his buttocks. NEUROLOGIC: Examination is grossly intact and normal.

PHYSICAL EXAMINATION:
VITAL SIGNS: Height 29 inches, weight 19 pounds. Head circumference 18-3/4 inches.
GENERAL APPEARANCE: He is normocephalic, atraumatic. The anterior fontanelle is open and flat.
SKIN: Fair.
HEENT: TMs normal bilaterally. Pupils are equal and reactive to light. Extraocular muscles intact. Negative cover test. Positive red reflex. Throat is negative.
NECK: Negative.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm with equal femoral pulses.
CHEST: A noticeable irregularity on his lower ribs.
ABDOMEN: Soft, positive bowel sounds. No hepatosplenomegaly with a very small umbilical hernia.
EXTERNAL GENITALIA: Genitalia show descended testes.
EXTREMITIES: Hips are negative.
NEUROLOGICAL: He is very alert. Good tone. Smiling and social. DTRs are equal. Cranial nerves intact, nonfocal.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 1945 g, head circumference 30.6 cm, length 44.8 cm. Temperature 36.6 degrees Celsius, heart rate 148, respiratory rate 80 to 108, blood pressure 48/20.
GENERAL: This infant is active, quiet, calm under the radiant warmer.
HEENT: Normocephalic. Anterior fontanelle soft and flat. Trisomy 21 face.
CHEST: Symmetric movement.
LUNGS: Clear to auscultation bilaterally.
HEART: A 2/6 murmur.
ABDOMEN: Soft with bowel sounds auscultated in all 4 quadrants. No hepatosplenomegaly.
GENITOURINARY: Normal male genitalia. Testes palpable bilaterally in the scrotum. Anus appears patent.
SPINE: Straight. No tufts, no clefts.
SKIN: Intact and warm.
NEUROLOGIC: Moro, suck, and grasp reflexes are elicited.

PHYSICAL EXAMINATION:
VITAL SIGNS: The baby’s birth weight was 3590, current weight is 3640, FOC is 35.6 cm, length is 49.7 cm. Temperature is 36.6, heart rate 170, respiratory rate 60, blood pressure 64/32.
GENERAL: Active and alert, in no acute distress.
HEENT: Anterior fontanelle is soft and flat. Sutures normally approximated. Ears are normally set. Palate is intact without defects. Red reflexes are present bilaterally.
NECK: Soft and supple without adenopathy. Clavicles are intact.
HEART: Regular rate and rhythm without S3, S4, no murmurs.
LUNGS: Clear to auscultation. No rales, rhonchi or wheezing.
ABDOMEN: Soft, nontender, without hepatosplenomegaly.
SKIN: Pink and well perfused. No rashes or lesions noted..

PHYSICAL EXAMINATION:
VITAL SIGNS: Height 27 inches, weight 17-1/4 pounds. Head circumference 17-1/2.
GENERAL APPEARANCE: He is a well-nourished, happy, alert, very social male in no acute distress.
SKIN: Fair.
HEENT: Anterior fontanelle is open and flat. TMs normal bilaterally. Pupils are equal and reactive to light. Red reflex bilaterally. Negative cover test. Extraocular muscles intact. Throat is negative.
NECK: Negative.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm with equal femoral pulses.
ABDOMEN: Soft, positive bowel sounds. No hepatosplenomegaly.
EXTERNAL GENITALIA: Descended testes bilaterally with circumcised penis.
EXTREMITIES: Hips are negative.
NEUROLOGIC: DTRs are equal. Puts weight on his legs. Very happy, very interactive, very vocal. Cranial nerves intact. Normal musculature. Normal tone. Nonfocal.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: She is a healthy-looking, 1-month-old infant. VITAL SIGNS: Length is 22-1/4 inches, weight is 9 pounds. Head circumference 14-1/2 inches. HEENT: Head is normocephalic. Anterior fontanelle is open and flat. Red-orange reflexes are positive in both eyes. Extraocular muscles are intact. Nose is clear. Mouth is clear. NECK: There is no neck mass. CHEST AND LUNGS: Symmetric. Good air entry. Clear breath sounds. HEART: Nonactive precordium. Normal first and second heart sounds, regular rhythm. No murmurs.
ABDOMEN: Soft. No hepatosplenomegaly. No mass. Umbilicus is dry. EXTERNAL GENITALIA: Normal female. EXTREMITIES: Femoral pulses are easily palpable. Hips are stable. Negative Ortolani and negative Barlow sign, and negative Galeazzi. SKIN: Clear. SPINE: Straight. No sacral dimple. NEUROLOGIC: Grossly intact.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: He is a healthy-looking toddler.
VITAL SIGNS: Height 34 inches, weight 29 pounds. Head circumference 28-1/2 inches.
HEENT: Head is normocephalic. Anterior fontanelle is now small, but still open. Red-orange reflexes are positive in both eyes. Both conjunctivae are clear. Pupils are equal and reactive to light. Nose is clear. Mouth is clear.
NECK: No neck mass.
CHEST AND LUNGS: Symmetric. Good air entry and clear breath sounds.
HEART: Normal. No murmurs, regular rhythm.
ABDOMEN: Flat, soft, no mass, no tenderness.
EXTERNAL GENITALIA: Normal male. Both testes are down.
EXTREMITIES: Full range of motion. No deformity. Negative Galeazzi sign.
BACK: Straight.
SKIN: Clear.
NEUROLOGIC: Examination is grossly normal.

PHYSICAL EXAMINATION:
GENERAL: He is awake, alert and in no acute distress.
VITAL SIGNS: Weight is 11 pounds 11 ounces. Temperature is 98.6, pulse 122 per minute, and respiratory rate 24 per minute.
HEENT: Head is atraumatic with a flat right occiput on the right temporal area. Red macular rash on his anterior neck area with some slight pressuring on either side with red macular rash under his right axilla. Eyes: PERRLA. Clear conjunctivae bilaterally. Ears: Normal TMs and canals bilaterally. Throat has no erythema.
CHEST: Lungs are clear bilaterally.
HEART: Normal S1 and S2. No murmurs.
ABDOMEN: Soft, nontender and no organomegaly.
LYMPHATICS: No enlargement.
NEUROLOGIC: Normal DTRs. Negative Babinski.

PHYSICAL EXAMINATION:
VITAL SIGNS: Today, vital signs are stable. She is afebrile.
SKIN: She has one deep pigmented spot and one cafe au lait spot, but no other significant dysmorphic features or skin stigmata.
HEENT: Anterior fontanelle is flat and soft.
CARDIAC: S1 and S2 are audible. No significant murmur.
ABDOMEN: Benign.
NEUROLOGIC: She is alert, active, not in acute distress. She is normocephalic. Extraocular movements are full. There is no facial asymmetry. Tongue is midline.
MOTOR EXAMINATION: Revealed normal tone and bulk. Deep tendon reflexes are 2+/4 bilateral, symmetrical, with flexor plantar responses.
SENSORY EXAMINATION: Revealed normal withdrawal. No dysmetria or tremors.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 22 pounds, temperature 98.2, pulse 104 per minute, and respiratory rate 24 per minute.
GENERAL: She is awake, alert, in no acute distress.
HEENT: Head atraumatic and normocephalic. AF open, flat. Eyes: PERRLA. Clear conjunctivae bilaterally. Ears: Normal TMs and canals bilaterally. Throat: No erythema.
LUNGS: Clear bilaterally.
HEART: Normal S1 and S2. No murmur.
ABDOMEN: Soft and nontender. No organomegaly.
LYMPHATICS: No enlargement.
SKIN: Hyperpigmented macules, diffuse on trunk, abdomen, legs and extremities. No petechiae.
NEUROLOGIC: Normal DTRs. Negative Babinski. Normal tone.

PHYSICAL EXAMINATION:
GENERAL: She is awake, playful, in no acute distress.
VITAL SIGNS: The patient has a weight of 21 pounds, temperature 98.4, pulse 120 per minute, respiratory rate 22 per minute, blood pressure 94/56.
SKIN: No rashes or petechiae.
HEENT: Eyes: PERL. Clear conjunctivae bilaterally. Ears: Normal TMs and canals bilaterally. Throat: No erythema.
HEART: Normal S1 and S2, within normal limits. Pulse is adequate.
LUNGS: Clear bilaterally.
ABDOMEN: Soft, nontender. No organomegaly.
GENITALIA: No rashes. Tanner I female.
LYMPHATICS: No enlargement.
EXTREMITIES: No deformity.
NEUROLOGIC: Normal tone.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 114, respiratory rate 30, blood pressure 112/52, weight 6.3 kilograms, height 64 cm, head circumference 41.8 cm, measurements are within normal limits.
GENERAL: The patient is alert, active, in no distress, well hydrated and well nourished. Capillary refill 2 seconds.
HEENT: Head: Normocephalic and atraumatic. Fontanelle flat. Eyes: Pupils equal and reactive to light and accommodation. Extraocular movements intact. No erythema or discharge. Fundi are normal. Vision is normal. Ears: Auricles normal. Canals are clear. Tympanic membranes are intact. Hearing is okay. Noted cerumen impaction bilaterally. Nose: Clear without discharge, symmetrical, no deformity. Throat: Clear without erythema or exudate. Tonsils are not enlarged. Normal oral mucosa and teeth.
NECK: Full range of motion of neck. No meningismus. No masses. Thyroid is normal. No lymph nodes enlarged anywhere.
CHEST AND LUNGS: Clear to auscultation bilaterally. No retractions, equal breath sounds.
HEART: Regular rate and rhythm. S1 and S2 normal. No clicks, murmurs or gallops.
BREASTS: Not applicable.
ABDOMEN: Nontender, nondistended, and soft. No organs enlarged. No masses.
RECTAL: Normal. Stool: Normal.
BACK: Straight spine. No deformity. Spine nontender. CVA nontender.
GENITOURINARY: Normal vulva. No discharge. Hymen intact.
EXTREMITIES: Gait not applicable. No joint swelling or tenderness. Full range of motion.
SKIN: Warm, dry, and pink. Turgor is normal; however, noted diaper rash is visible, satellite lesions, and erythema of bilateral buttocks. However, no lesions of groin, skin folds.
NEUROLOGIC: Sensorium is intact. Cranial nerves are intact. Motor and sensory are intact. Cerebellum intact. Deep tendon reflexes 2+ in all extremities. Development is normal.

PHYSICAL EXAMINATION:
GENERAL: Well-developed, well-nourished male child, appears comfortable.
VITAL SIGNS: Stable, normal, afebrile, O2 saturation is normal at 98% on room air.
ENT: Moist mucous membranes. Airway patent. He does have a hyperemic posterior pharynx with some enlarged tonsils but no exudate, no airway obstruction. Some clear rhinorrhea and edematous nasal turbinates of the nose. Ears reveal hyperemic TMs bilaterally with no bulging. No loss of landmarks.
NECK: Supple, no nuchal rigidity. No significant lymphadenopathy.
HEART: Regular rate and rhythm, S1, S2.
LUNGS: Mostly clear to auscultation bilaterally. No retractions or accessory muscle use.
ABDOMEN: Soft, nontender. Bowel sounds are present.
SKIN: Warm and dry.
EXTREMITIES: Without cyanosis.
NEUROLOGIC: He was sleeping initially but he woke up, responds normal to any tactile stimulation. Makes good eye contact. Fontanelle is fused.

PHYSICAL EXAMINATION:
GENERAL: Well-developed, resting in mother’s arms, nontoxic.
VITAL SIGNS: Temperature is 99.2, pulse 120, respirations 46, room air pulse ox 98%, within normal limits.
HEENT: Anicteric sclerae. Good red reflex. Pupils are equal, round, and reactive to light. Bilateral TMs clear. Normal anterior fontanelle. Oropharynx is clear. Moist mucous membranes. Chest wall is without crepitation.
HEART: Regular rate and rhythm without murmurs.
LUNGS: Clear to auscultation bilaterally, no signs of intercostal retractions or respiratory extremis, very tight.
ABDOMEN: Soft, positive bowel sounds, nontender.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Good Moro reflex. Reflexes are 1+. Moves all four extremities. Good suck reflex.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 2760 g, length 48.4 cm, head circumference 33.2 cm, temperature 37.2 axillary, heart rate 122, respiratory rate 62, blood pressure 68/46.
GENERAL: Term male, in no distress.
HEENT: Normocephalic. Anterior fontanelle is open and flat. Eyes and ears are grossly normal. Nares patent. Palate intact. Clavicles supple. Red reflex present on admission.
THORAX: Symmetric.
LUNGS: Bilateral breath sounds are clear and equal.
CARDIOVASCULAR: Heart rate and rhythm regular without a murmur. Precordium is silent. Pulses are 2+ and equal. Capillary refill is brisk.
ABDOMEN: Soft, round with active bowel sounds. No hepatosplenomegaly or masses noted. Cord intact and dried.
GENITOURINARY: Male genitalia with testes descended bilaterally. Anus patent.
MUSCULOSKELETAL: Spine alignment is within normal limits. Appropriate number and spacing of digits. Hip exam is within normal limits.
NEUROLOGIC: Infant is active, alert, moves all extremities well. Tone is appropriate for age.
SKIN: Intact and pink.

PHYSICAL EXAMINATION: The baby is alert, awake, active, and in no distress. Head is clear. Ears, nose, and throat are clear. Neck is supple. No masses. Respiratory system is clear bilaterally. No wheezing. No rales. Cardiovascular system: S1, S2, rhythmic, no murmurs. Abdomen is soft and nontender. No hepatosplenomegaly. No masses. Skin: There is a faint, thin erythematous rash over the arm and trunk. No purpuric blanching. Extremities are normal. CNS: Nonfocal. Anterior fontanelle is open and flat.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 96.4, rectal; pulse 146; respirations 34; pulse oximetry 92-93% on room air. This was repeated and found to be at 99%.
GENERAL: This is a 4-day-old male child. He has his eyes closed. He is uncovered. He is moving his arms and legs vigorously. He is not crying. He does not appear jaundiced. His skin does appear very dry and some areas are peeling.
HEENT: The head is normocephalic and atraumatic. The anterior fontanelle is without depression or bulge. The pupils are equal, round, and reactive to light. He also has a good red light reflex. Oropharynx is normal without erythema, edema or exudate. No signs of thrush. He is age appropriate. The mucous membranes are moist. He does have a greenish discharge in the left naris. There is no edema noted in the turbinates or erythema.
NECK: Supple without meningismus. There is no lymphadenopathy.
LUNGS: Clear to auscultation. Equal breath sounds bilaterally. No wheezes, rales, rhonchi, crackles or stridor noted. Respiratory excursion is symmetrical. No sternal retractions.
HEART: Regular rate and rhythm. No murmurs, gallops, rubs or clicks.
ABDOMEN: Soft, nontender, nondistended. There are no masses or organomegaly. Positive bowel sounds, all four quadrants. No guarding or rebound.
SKIN: Warm and dry. Again, it does appear very dry, and in places, it is peeling. His hips have no clicks. He was just circumcised yesterday. The glans penis is slightly erythematous and does not appear to be infected. The right testicle is down; left testicle is not. There is no diaper rash. The rectum appears normal.

PHYSICAL EXAMINATION: His weight is 4.9 kg, blood pressure is 89/54. HEENT: Flat fontanelle. Lungs: Clear breath sounds. Heart: S1 and S2, normal. No murmur. Abdomen: Soft and full abdomen. Spleen is 2 cm. Liver is up to umbilicus. Genitalia: Normal male features with micropenis. Testes descended bilaterally. Neurological: Responsive, active, intact. Spine: Straight, without masses. Moving all extremities. Skin: Pink and warm.

PHYSICAL EXAMINATION: On general examination, the child is healthy in appearance. He is in no apparent distress when held in his mother’s lap. Examination of head and neck does not demonstrate any significant abnormality. His sclerae are normal in color. Examination of the upper extremities and trunk is normal. On examination of lower extremities, he has some slight swelling of the right thigh. He is clearly tender to palpation of the right thigh. He does not seem to be tender to palpation over the lower leg, ankle or foot. He does have some apparent pain with movement of the right lower extremity. He does not tend to move the right hip and knee as much as the left. The left lower extremity does not seem to be tender over the thigh, knee or lower leg.

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Infant Physical Exam Terms & Phrases for MTs:

anal wink

anterior fontanelle open and flat

Apgar score

birth OFC of ( ) cm

body measures ( ) cm from crown to heel

caput succedaneum

choanal atresia

clavicles and limbs were grossly normal without deformities

cleft lip

cleft palate

clunk (hip clunk)

coarctation of the aorta

congenital cataracts

cremasteric reflex

dancing reflex

Down syndrome

Epstein pearls

facial grimace

facies are normal

fetal alcohol syndrome

good eye tracking

good strong tone

hard palate is intact

head circumference

hypertelorism

hypospadias

hypotelorism

infant was moving all extremities

kyphosis

lordosis

low-set ears

macrocephaly

macroglossia

macrostomia

meningomyelocele

microcephaly

micrognathia

microstomia

nasal bridge is normal

no hip click

normal red reflex bilaterally

Ortolani maneuver (or Ortolani test)

overriding sutures

palm lines are examined and are not unusual

palmar grasp reflex

placing reflex

positive grasp

positive grasp reflexes

positive Moro

positive root

positive suck

posterior choanal canals can be probed

radial-femoral delay

rooting reflex

scoliosis

stepping reflex

subcostal recession

sucking reflex

symmetric Moro reflexes were elicited

tendon reflexes were brisk

tonic neck reflex

tracheal tug

Treacher Collins syndrome

truncal incurvation reflex

Turner syndrome

vigorous cry

webbed neck

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