Physical Exam Medical Transcription Normals

VITAL SIGNS: Pulse is 74 and regular, respirations 18 and regular, and blood pressure 124/78.
GENERAL: Well-developed, well-nourished Hispanic male in no acute distress. Alert and cooperative.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Pharynx is clear. Tympanic membranes are normal.
NECK: Supple. No thyromegaly. No cervical adenopathy.
CHEST: Symmetrical with equal expansion.
LUNGS: Clear to percussion and auscultation.
HEART: No cardiomegaly. No thrills or murmurs. Normal sinus rate and rhythm.
ABDOMEN: There is slight left flank tenderness to deep palpation. There is no guarding or rebound tenderness. Bowel sounds are normal.
EXTREMITIES: No peripheral edema or varicosities.
GENITALIA: Normal external male genitalia. No penile lesions. Testes are descended bilaterally and are normal to palpation.
RECTAL: The prostate is small, benign, and nontender.

PHYSICAL EXAMINATION:  Vital signs were stable, afebrile. He has tenderness over the right cervical region upon palpation. There was a 2 cm indurated, raised, and well-circumscribed swelling in the right submandibular gland region. The right submandibular gland duct was noted to be absent of any salivary flow. No purulent discharge was observed, however.

PHYSICAL EXAMINATION:  The patient is lying in bed, sleepy but arousable. Vitals: Temperature 98.4, heart rate 108, blood pressure 78/54, T-max 104.2. HEENT: Atraumatic and normocephalic. Pupils are equal. No conjunctival hemorrhage. No sinus tenderness. No oral lesion. Neck is supple. No lymphadenopathy. Chest: Bilateral rales, posterior half. Heart: S1, S2 audible. No murmurs or rubs. Abdomen: Soft. Bowel sounds audible. There is mild tenderness in the right upper quadrant. No guarding or rigidity. Extremities: No edema, clubbing, or cyanosis. Few pigmentary lesions in the lower and upper extremity.

PHYSICAL EXAMINATION:  At this time demonstrates an alert and oriented female in no acute distress. She denies any complaints and wants to go home. Her blood pressure is 120/68, heart rate is 72 and regular, and she is afebrile. HEENT: Anicteric sclerae. Jugular venous pressures are elevated, but no carotid bruits are noted. She has clear lung fields. Chest: Healed, stable sternotomy incision. Heart: S1 normal. A2/P2 normal. There is a harsh 2 to 3/6 systolic murmur with peaks in late systole and obscures the second heart sound with a single component. There is a third heart sound noted. There is 1/6 diastolic murmur suggestive of aortic insufficiency. Abdominal exam is negative. Extremities are free of cyanosis and clubbing. There is an ankle edema and an ecchymotic area over the left ankle.

PE Sample 1

PHYSICAL EXAMINATION:  Blood pressure is 144/74, pulse 86, and respirations 18. The patient is afebrile at 96.8. The patient is a (XX)-year-old Caucasian female looking much older than stated age. Alert and oriented. Skin is warm and dry, pink and nonicteric. Sclerae nonicteric. Oral mucosa is pink and moist. No lesions noted. Neck: No lymphadenopathy or thyromegaly. Chest: Clear, bilaterally expanded. Respirations are even and unlabored. Heart: S1 and S2. No rubs, murmurs, or gallop. Abdomen: Soft, very tender from right lower quadrant up and across upper abdomen. Bowel sounds are present throughout. Unable to assess organomegaly secondary to patient’s discomfort. The patient moves all extremities well and equal.

PHYSICAL EXAMINATION:  The patient is alert, oriented, pleasant. He has an NG tube in place, which is draining scant fluid, which has a tinge of red. His head is without evidence of trauma. No balding pattern is noted. His sclerae are clear. Conjunctivae pink. Pupils react to light and accommodation. Extraocular muscles are intact. Neck is without lymphadenopathy or thyromegaly. Tongue is in the midline. Articulation is clear. There is no glossitis or angular stomatitis. Heart has regular rate and rhythm without murmur, rub, or click. Lungs are clear without rales, rhonchi, or wheezing. The abdomen is soft. There is moderate tenderness to moderate palpation in the right and left lower quadrant. There is no guarding or rebound. There is no rigidity. There is no ecchymosis of the periumbilical area or flanks. There is no organomegaly. The spleen is not enlarged to percussion or palpation nor his liver. Extremities are without cyanosis, clubbing, or edema.

PHYSICAL EXAMINATION:  Initial blood pressure 152/84, temperature 99.6, and pulse 94. The patient is awake, alert, and in no apparent distress. No extremity swelling. Normal peripheral pulses. Gait not tested. Normal strength in the upper and lower extremities. Normal tone without any atrophy. Reflexes are 2+ and symmetric. No clonus. Normal orientation, concentration, memory, language, and fund of knowledge. Cranial nerves II through XII are intact. Vision is grossly normal. Extraocular muscles intact. Normal facial sensation and normal facial strength. Palate elevates in the midline. Normal shoulder shrug. Tongue does not deviate. No dysmetria with finger-to-nose. Negative Romberg. Normal coordination.

PHYSICAL EXAMINATION:  On examination, the patient is frail and looks very wasted, but she is oriented x3. Her blood pressure is 92/72 and the JVP is not elevated. Trachea is midline. Thyroid is not enlarged. Heart rate now is 92, normal sinus rhythm. She was in atrial fibrillation. She has a harsh pansystolic murmur heard over the left parasternal area, and she also has 3/6 mitral regurgitation murmur. She has a soft murmur across the aortic valve. Cardiomegaly was noted clinically. Lungs demonstrate decreased breath sounds at the bases. The skin is very thin, flaky, and dry. Abdominal examination is negative. No masses.

PHYSICAL EXAMINATION:  Blood pressure is 110/62, pulse 68, and temperature 97.6. Elderly frail female, lying in the bed. On cranial nerve testing, she has severe visual acuity problems, but her extraocular movements appeared intact. Her face shows left nasolabial fold flattening. Tongue and palate are midline. Corneal reflexes are symmetric. On motor testing, she has a left hemiparesis, power is 3/5 and right-sided power is 4+/5. Coordination reveals no dysmetria on the right. Deep tendon reflexes are 3+ on the left and 2+ on the right. Gait is deferred.

PHYSICAL EXAMINATION:  Blood pressure is currently 82/52 with a pulse of 84 and T-max of 98.6. The patient states that her blood pressure usually runs in the 80s systolic. Head normocephalic. No masses or tenderness. Pupils symmetric. Sclerae with positive icterus. Mouth with dry mucous membranes. Normal tongue. Neck: No JVD. No thyromegaly. Lungs: Diminished breath sounds, particularly on the right, otherwise symmetric excursions. Cardiac: Normal S1 and S2. No murmurs, gallops, or rubs. Abdomen: Grossly distended with positive succussion splash. Extremities: Actually show no clubbing, cyanosis, or edema. Skin: Icteric. No ulceration seen. No petechiae or purpura are present. Neurologic: The patient is alert and oriented x3 with a nonfocal neurological exam. Left upper extremity contains a PICC line.

PE Sample 2

PHYSICAL EXAMINATION:  The patient is sitting on the chair, a very conversant and good historian. Blood pressure is 112/82, heart rate is 88, and respiratory rate is 14. She is afebrile. Skin has normal color with no areas of ischemia, blue toes, or infarctions or embolization. HEENT: There is a little puffiness of the face. Neck is supple without JVD. Lungs are clear. Heart has a regular rhythm. Abdomen is negative for masses, megalies, or bruits. Extremities show 1+ bilateral edema.

PHYSICAL EXAMINATION:  Alert and oriented, in no acute distress, lying comfortably in bed. She is afebrile. Pulse 76, respirations 18, blood pressure 100/62, O2 saturation 100% on room air. HEENT: No pallor, icterus or oropharyngeal lesions. NECK: No JVD. No bruits. Normal carotid upstrokes bilaterally. CHEST: Clear. CARDIAC: Regular rate and rhythm. Normal S1, S2. No S3 or S4. No murmurs. ABDOMEN: No mass, bruit or organomegaly. EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ bilaterally.

PHYSICAL EXAMINATION:  Alert, elderly woman, in no apparent distress, who is afebrile with a blood pressure of 110/66 and pulse of 66 and regular. There is a faint right carotid bruit. Heart exam reveals bradycardia, normal S1 and S2 heart sounds. The patient is oriented to person and day of the week only. She thinks it is 1986. She cannot name the president or vice president. She cannot name her medications or treating physicians. She has no knowledge of current events. She has limited insight into herself and overall situation. Speech is characterized by short phrases with ability to follow some two-step commands. Naming of objects is normal. There is impaired ability to perform all calculations, except the most simple additions. Pupils are equal and reactive to light. Extraocular movements are full without nystagmus. Visual field testing is full to finger count. Fascial movements are symmetric. Motor exam demonstrates 5/5 strength throughout all four limbs. The patient deferred on standing at this time. Deep tendon reflexes are 2+ throughout the upper limbs, 1+ at the knees and ankles. Plantars are flexor.

PHYSICAL EXAMINATION:  Temperature 96.8, blood pressure 98/64, heart rate 90, respirations 20. This is a Hispanic female who appears to be in no acute distress. She is alert, awake, and oriented x3. Heart: She has a regular rate and rhythm. Lungs: Clear to auscultation. Abdomen: At the site of the G-tube, there is a Foley present. J-tube noted. She has mild erythema and slight drainage around the J-tube. She is on TPN feedings right now. Abdomen: Otherwise soft, obese, nontender, and nondistended. No rebound or guarding. Extremities: She has left leg edema, mostly 3+, with erythema. Rectal: Deferred.

PHYSICAL EXAMINATION:  Afebrile. Blood pressure 118/66, heart rate is 52, respirations 16. The patient looks older than his stated age, in no acute distress. HEENT: Normocephalic, atraumatic. Neck: Supple. No jugular venous distention or carotid bruits. Lungs: Clear. Respirations are unlabored. Heart: Regular rate and rhythm. S1 and S2. No frank extra heart sounds or murmurs. Abdomen: Soft and nontender. Bowel sounds present. Extremities: No peripheral edema. Neurologic: Alert, oriented, grossly nonfocal.