Physical Exam Medical Transcription Samples and Examples


PHYSICAL EXAMINATION:
GENERAL:  The patient is awake and alert.
VITAL SIGNS:  Temperature in the ER was 100.6 degrees, has been 99.6 degrees since then, currently 98.4 degrees.  Pulse 102, respirations 22 and blood pressure 132/78.
HEENT:  Normocephalic and atraumatic. Pupils are equal and reactive to light.
NECK:  Supple. No JVD.
HEART:  S1, S2, regular. No heart murmurs.
LUNGS:  Decreased air entry bilaterally.
ABDOMEN:  The patient was morbidly obese. He had an ileostomy that was functioning. There were no masses palpable and there was no distention, rebound or guarding.
EXTREMITIES:  The patient had swelling of both his legs. Both of them were somewhat edematous. There was a wound that was draining some yellowish drainage on the left lower leg. The dressing had that same drainage. The right leg was not warm, hot or tender. In fact, pulses were good and there was no groin adenopathy other than swelling, which was present before. There was no new abnormality. There is no calf tenderness.

PHYSICAL EXAMINATION:
GENERAL:  The patient appears older than her stated age.  Her body habitus is ectomorphic and she is markedly asthenic.
VITAL SIGNS:  Currently stable.  She has a mild systolic hypertension.  The patient is afebrile.
SKIN:  No skin rashes or lesions are noted.
HEENT AND NECK:  The head is normocephalic and atraumatic.  The head and neck are nontender without thyromegaly or adenopathy.  Carotid upstrokes are 1+/4.  No cranial or cervical bruits.  Neck is supple with full range of motion.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation.
ABDOMEN:  Soft and nontender.
BACK:  Straight without midline defect.
EXTREMITIES:  No cyanosis, clubbing or edema in the extremities.
NEUROLOGIC:  Higher Cortical Function/Mental Status:  The patient is alert.  She is oriented x1 to person.  She does not know the day or date.  There is no gross evidence of aphasia or agnosia.  She is moderately dyspraxic on performance of commands.  Her recent and remote memory appears poor.  She has a poor fund of knowledge.  Cranial Nerves:  Pupils 3 mm, reacting sluggishly to 2 mm without afferent pupillary defect.  The visual fields cannot be tested due to poor cooperation.  Funduscopic examination cannot be completed due to poor cooperation.  Extraocular movements are full and smooth with normal pursuits and saccades.  No nystagmus is noted.  The face is symmetric.  The remainder of the cranial nerves appears intact and symmetrical.  Strength:  Difficult to assess.  The patient has marked pronator drift of the outstretched right upper extremity.  Proximal upper extremities are about 4/5.  Intrinsic muscles of the hand on the right 3/5 versus 4+/5 on the left.  The patient is able to lift her left lower extremity off of the bed; in contrast, she can only slightly wiggle her toes on the right and can slightly raise her knee on the right.  Given some time, she performs strength testing slowly but a little better.  Tone is normal.  Bulk demonstrates moderate atrophy, distal more so than the intermediate muscles.  No involuntary movements noted.  Reflex is 1-2/4 and symmetric in the upper extremity, 2+/4 and symmetric at the knees.  Trace at the Achilles tendons.  Plantar responses are downgoing bilaterally.  Sensation:  Intact to pinprick and light touch.  Vibratory sensation is reduced in distal lower extremities.  Coordination:  The patient normally performs finger-to-nose-to-finger testing with the left but it is mildly impaired on the right due to weakness.  She is able to perform heel-to-knee-to-shin maneuver on the left but cannot on the right due to weakness.  Rapid alternating movements are diffusely impaired.  Gait and station unable to test at this time.

PHYSICAL EXAMINATION:
GENERAL:  The patient is pleasant, appears her stated age.  Body habitus is mesomorphic.
VITAL SIGNS:  Currently stable.  The patient is afebrile.
SKIN AND EXTREMITIES:  No skin rashes or lesions are noted.  No cyanosis, clubbing or edema of the extremities.
HEAD AND NECK:  Head is normocephalic and atraumatic.  The head and neck are nontender without thyromegaly or adenopathy.  Carotid upstrokes 1+/4.  No cranial or cervical bruits.  The neck is supple.  She appears to have full range of motion, but examination is limited due to the patient's vertigo.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation.
ABDOMEN:  Soft and nontender.
BACK:  Straight without midline defect.
NEUROLOGIC:  High Cortical Function/Mental Status:  The patient is alert.  She is oriented x3 to time, place and person.  There is no gross evidence of aphasia, apraxia or agnosia.  Her recent and remote memory appears normal.  She has a better-than-average fund of knowledge.  Cranial Nerves:  Pupils 4 mm, reacting briskly at 2 mm without afferent pupillary defect.  Visual fields are intact to confrontation testing.  Funduscopic examination reveals sharp disc margins, normal vasculature, no papilledema, hemorrhages or exudates.  Extraocular movements are full with normal pursuits and saccades.  No significant nystagmus is present.  There is mild end-gaze nystagmus, which extinguishes in both extreme directions of gaze.  Face is symmetric.  Remainder of the cranial nerves are intact and symmetrical.  Strength 5/5 throughout with tone and bulk with the following exceptions, 4+/5 intrinsic muscles of the hands and feet, no involuntary movements noted.  Reflexes 1/1 and symmetrical in the upper extremities, absent in the lower extremities.  Plantar responses are downgoing bilaterally.  Sensation intact to pinprick, light touch, vibration and proprioception.  Coordination:  The patient normally performs finger-to-nose-to-finger, heel-to-knee-to-shin and rapid alternating movements in a symmetrical fashion.  Gait and station could not be tested at this time.

PHYSICAL EXAMINATION:  Temperature 98.4 degrees, pulse 84, respirations 18, blood pressure 110/72. This is a well-nourished female in no apparent distress. Neurologically, the patient is somnolent. She needs repeated stimulation to stay aroused. Her speech has decreased fluency, is hypophonic, and not fully appropriate. Does a great deal of mumbling in between, can get her to answer questions at times appropriately. She is only able to name 2 of 6 objects presented to her. Short-term memory is untestable. Attention span is severely decreased. The patient was able to name the current president only. Motor exam reveals patient's left upper extremity to be 5-/5 proximally and 4/5 distally with increased tone. The patient's left lower extremity is in traction. She does have upgoing toes on the left. Right upper extremity is 5-/5 proximally and 5-/5 distally with no increased tone. The patient's right lower extremity has increased tone and it is 2/5 proximally and distally. The patient has upgoing toes bilaterally. Deep tendon reflexes are symmetrical in all four extremities. I was unable to appreciate any clonus in this patient. The patient was unable to cooperate with fine motor testing. I was unable to test patient's gait. Sensory exam is grossly intact. The patient did respond appropriately to painful stimuli in all four extremities. Cranial Nerve Exam:  Pupils are equal and reactive at 3 mm and brisk. Extraocular muscles intact. Visual fields are intact to threat. Accommodation was untestable. Corneal reflex intact. Hearing grossly intact. There is no gross facial asymmetry. The tongue is midline with good palate elevation. S1, S2, regular. No murmurs, gallops or clicks appreciated. Pulses are present in all extremities.

PHYSICAL EXAMINATION:  Vital signs and BMI are recorded in chart. HEENT:  TMs are normal. There is cerumen in both canals. Nose reveals a deviated septum. Oropharynx shows cleft palate repair. Funduscopic is benign. Neck is supple without adenopathy, thyromegaly or bruits. Lungs are clear. Chest reveals a pectus excavatum repair. Heart:  Regular without gallop or murmur. Abdomen is soft, nontender, without hepatosplenomegaly. Extremities:  There is above-the-knee amputation on the right. No cyanosis or edema on the left. Genitourinary is unremarkable. Rectal reveals a smooth, symmetric prostate. Skin:  There is a hemangioma noted at the lower left flank, which is benign appearing. There is an inflamed follicular nodule on the right scapula. Neurologic is nonfocal.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature tactilely afebrile, blood pressure 130/88, weight 262, height 5 feet 9 inches.
GENERAL:  The patient is a well-developed, well-nourished male in no acute distress, oriented x3.
HEENT:  Normocephalic, atraumatic. Extraocular muscles are intact. Conjunctivae pink. Sclerae anicteric. Pupils equal, round and reactive to light. Fundi sharp with no exudate or hemorrhages. Tympanic membranes clear. Nasal mucosa normal. Septum midline. No purulent exudates. Buccal mucosa moist, no lesions. No caries, no pharyngeal injection, no exudate.
NECK:  Supple, no carotid bruits, no adenopathy. Thyroid normal size, shape and contour.
CARDIAC:  Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS:  Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
ABDOMEN:  Bowel sounds present, nontender, nondistended. No hepatosplenomegaly. No masses detected. No deformity, no CVA tenderness.
EXTREMITIES:  No cyanosis, clubbing or edema. No varicosities noted. DP pulses +2 in bilateral extremities.
MUSCULOSKELETAL:  Normal gait and grossly nonfocal.
NEUROLOGIC:  Cranial nerves II through XII grossly intact. Sensation intact to fine touch bilaterally and to vibration in bilateral lower extremities. Deep tendon reflexes equal bilaterally. Babinski's equivocal. Motor strength 5+ throughout.
DERMATOLOGIC:  No exanthems, no suspicious lesions. The patient is noted to have skin tags around the neck.

PHYSICAL EXAMINATION:  Blood pressure is 112/68, pulse is 72, respirations 18 and unlabored.  Weight is stable with a mild weight gain secondary to hormone use.  Funduscopic exam shows clear disk margins.  There is no AV nicking or papilledema visualized.  Pupils are equal, round and reactive to light.  Pupils are large and constrict down to 2-3 mm.  They are symmetrical and equal in accommodation.  There may be a slight lag on the left but there is consensual movement.  Visual fields are intact.  Extraocular movements are intact.  Finger-to-nose and heel-to-shin are intact.  There is no lateral gaze nystagmus, lid lag, lid ptosis or facial lag.  Tongue is midline.  Palate elevates symmetrically.  Sensory changes, mid cheek and periorbital, around the right eye to the temporomandibular joint on the right, lower dermatome and upper dermatome and upper forehead.  Sensation to light touch, hot and cold and pinprick are all intact.  The patient also has sensory changes in the right lower extremity from the mid brachioradialis down.  Skin is warm and dry with good palpable pulses and good capillary refill.  There is no edema, no skin color changes or temperature changes.  Otherwise, sensation is intact, mid thoracic all the way down to the toes, intact to hot, cold and pinprick as well as light vibration.  Reflexes are symmetrical, they are more normoreflexic in the brachioradialis and wrist flexors, patellar and Achilles are slightly more hyperreflexic being a 2+ and toes are mute on the left.  This was repeated and rechecked.  The patient has a negative Myerson's sign.  Has negative jaw clonus.  There is negative ankle clonus.  There is negative upper extremity myoclonus.  Muscle bulk, strength and tone are grossly intact with some focal discrepancies in the right hand with regard to specific groups.  The patient has flexor digitorum profundus as well as flexor carpi ulnaris and abductor digiti minimi as well as flexor digiti minimi and all digits including the adductor pollicis.  There is some mild giveaway weakness in both hands, it is more pronounced in the right than the left, and would evaluate the patient at about a 4+/5 for the left hand and a 4 to 4+/5 on the right hand.  Normal heel-to-toe strike and stride.  Arm swing is normal.  The patient self-corrects for Romberg.  Although has difficulty performing tandem gait, the patient is able to do so and also walks well on heels and toes.  There is no involuntary movement.  The patient is right-handed.  Carotid sounds are normal.  Heart sounds are normal without click or murmur and distal extremities have easily palpable pulses with good skin temperature and tone.

PHYSICAL EXAMINATION:  The patient is alert and oriented to person, place and time. Language and praxis are intact. The patient has mild bradyphrenia and also frequently gets off topic and has some difficulty answering questions clearly.  Cranial Nerves:  Pupils equally round and reactive to light. Disks are sharp. Extraocular movements reveal the following:  The patient has slowed saccades horizontally and with downgaze. Has absent upward saccades. Smooth pursuit movements are similarly slowed and have some saccadic breakdown in the horizontal plane. Has absent vertical upward smooth pursuits. Has frequent square wave jerks. There are occasional beats of nystagmus on end-gaze in both directions, which is direction changing. There is no nystagmus in mid position. Disks are sharp. Visual fields are full to confrontation. Facial sensation is intact to light touch in all distributions. Face is symmetric. Hearing is intact to conversational tone. Palate elevates symmetrically and tongue is in the midline.  Has a little bit of monotonous ataxic speech pattern. Has moderate hypomimia with somewhat deepened nasolabial folds. Voice is of normal volume. Tone in the neck is increased to a 2 on the UPDRS. Shoulder shrug is intact bilaterally. Has very mild dysarthria, especially for pharyngeal consonants. Motor:  Has full strength and normal tone in the extremities. Has some increased tone at the neck. Has somewhat slowed clumsy movements with finger tapping but pronation, supination, opening, closing movements of the hands are intact. Has stimulus-evoked myoclonus in the left upper extremity. Do not detect any tremor with rest or with posture. There is just a slight action tremor bilaterally. There is also a question of perhaps just slight dystonia when the left arm is outstretched and there seems to be mild pronation when the patient holds the left arm outstretched.  Sensory:  Has intact light touch and temperature. Vibratory sense appears to be diminished in the left toe to the level of the left knee. Does report intact vibratory sense in the right lower extremity. Joint position sense is intact on the right and may be just slightly impaired in the left lower extremity. There are no cortical sensory signs and graphesthesia and stereognosis intact bilaterally. Has no extinction to double simultaneous stimulation.  Deep tendon reflexes:  These are very brisk and 3+ everywhere, except at the ankles, where they are trace. Right toe is clearly downgoing. The left toe is equivocal.  Coordination:  Intact finger-to-nose testing with no dysmetria. Gait:  The patient requires two hands to push herself up from a seated position. When she stands on her own, she looks very unsteady and tends to have a widened base. She is unable to walk without a walker or one-person assist. When she walks with me, she has a quite ataxic gait and clearly has difficulties visually scanning her environment. She has spontaneous retropulsion.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 124/70, heart rate 84, respiratory rate 21, temperature 97.8 degrees, satting 94% on 2 liters.
GENERAL:  The patient is an obese lady, lying down on the bed, not in any acute distress. She looks older than her age.
HEENT:  Pupils are round and reactive to light, pink conjunctivae. Oral cavity, no lesion, no thrush.
NECK:  No thyromegaly and no adenopathy. Trachea is midline. No JVD.
LUNGS:  Clear to auscultation in the left, decreased breath sounds on the right with dullness to percussion. There is no wheezing or rales.
HEART:  S1 and S2. No murmur.
ABDOMEN:  There is no pain, no tenderness, no distention and no organomegaly. Bowel sounds positive.
EXTREMITIES:  Shows +1 edema in the lower extremities. Pulses are +2.
SKIN:  Shows there is a rash on the buttock and the back and the skin was warm.
NEUROLOGIC: Alert and oriented x3. No focal deficits.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4 degrees, pulse 72, respirations 18, blood pressure 158/70 and O2 saturation 100% on room air.
GENERAL:  The patient is awake, alert and oriented, in no acute distress.  He is well nourished and well developed.
HEENT:  Normocephalic and atraumatic.  Pupils are equal and reactive to light and accommodation.  Extraocular movements are intact.  No jaundice.  No sinus tenderness.  Oral mucosa is pink and moist.  No exudate.
NECK:  Supple and symmetrical.  Right-sided scar from previous carotid endarterectomy.  No enlarged thyroid.  No adenopathies.  No jugular vein distention.  The patient has a left carotid bruit.
CHEST:  Symmetrical with midline surgical scar from previous coronary artery bypass graft surgery.
LUNGS:  Clear to auscultation.  No wheezes or rales.
HEART:  Regular rate and rhythm, S1 and S2.  No murmurs or gallop.
ABDOMEN:  Soft and nontender.  Bowel sounds are present.  No peritoneal signs.  No guarding.  No visceromegaly.  No palpable masses.  No detectable bruits.
RECTAL:  Examination not performed at this time.
EXTREMITIES:  No edema or cyanosis.  No calf tenderness.  Surgical scar from vein harvesting for coronary artery bypass graft surgery present.  Slightly decreased pulses in the lower extremities.
NEUROLOGICAL:  The patient is awake, alert and oriented x3.  No focal, sensory or motor deficits.
SKIN:  The patient has hyperpigmented lesions in the lower extremities.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 180/84, pulse 78, respiratory rate 18, temperature 98.4, pulse oximetry 98% on room air.
GENERAL:  The patient is alert and oriented x3, in no acute distress. The patient is immobilized on backboard and C-collar. GCS of 15.
HEENT:  Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx clear. Mucous membranes moist. There is no orbital stepoff or deformity. No raccoon eye. No hemotympanum. No Battle sign. No otorrhea. No rhinorrhea. No nasal septal hematoma. The orbits, nasal bones, mid face, mandible are atraumatic.
NECK:  Supple, nontender to palpation, no lymphadenopathy, no masses, no JVD, no carotid bruits, no meningismus. C-Spine nontender to palpation.
CHEST:  Clear to auscultation bilaterally. Atraumatic.
CARDIAC:  Regular rate and rhythm. No murmurs, rubs, or gallops.
ABDOMEN:  Bowel sounds are present. The belly is soft, nontender, nondistended. No masses, no hernias, no rebound, no guarding.
BACK:  No CVAT. T and L spine nontender to palpation.
EXTREMITIES:  Distal pulses 2+ bilaterally. No clubbing, cyanosis or edema. Pelvis is stable to rock. Log roll was negative bilaterally. No evidence of extremity trauma anywhere.
SKIN:  No rash, no petechiae, no purpura, no jaundice.
PSYCH:  Normal mood, normal affect.
NEUROLOGIC:  Alert and oriented x3, normal mental status. Cranial nerves II through XII intact. Strength 5/5 bilaterally throughout

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 122/78, heart rate 88, respiratory rate 16, temperature 98.4 orally and O2 saturation 98% on room air. 
GENERAL: This is a well-appearing (XX)-year-old man in no acute distress. 
HEENT:  Normocephalic and atraumatic. Oropharynx is clear. Mucous membranes are moist. Pupils are reactive to light. The right pupil is round. The left pupil has an eccentric shape but is approximately equal in size to the right and reactive both directly and consensually. Visual acuity 20/100 in the right eye and 20/200 in the left eye. Intraocular pressure with a Tono-Pen is 12 and 14 in the right eye and 12 and 14 in the left eye. Slit-lamp exam reveals some punctate areas of fluorescein uptake in the left eye, no uptake in the right eye. There are no cells or flare seen in either eye. Funduscopic exam is limited and unable to visualize the retina of either eye. Extraocular movements are intact. Sclerae anicteric and without injection bilaterally. There is no drainage from either eye. 
NECK: Supple. Trachea is midline. 
CHEST: Clear to auscultation bilaterally. 
CARDIOVASCULAR: Regular rate and rhythm. 
ABDOMEN: Soft and nontender. 
NEUROLOGIC: He is alert and oriented x4 with a normal nonataxic gait.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6, pulse 64 and regular, respiratory rate 22, blood pressure 138/58, height 5 feet 10 inches, weight 210 pounds.
HEENT:  Eyes:  Pupils are 4 mm, equal, round, and reactive to light.  Extraocular movements intact.  Left eye, status post cataract surgery.  Noninjected sclerae.  Conjunctivae and lids without exudate.  Ears:  With bilateral hearing aids.  Positive light reflex bilaterally, minimal cerumen.  Nose:  Nasal turbinates are erythematous and edematous with clear nasal drainage.  Oropharynx:  Some missing teeth, but good dental hygiene.  Moist mucous membranes without erythema, exudate or lesions.
LUNGS:  Clear to auscultation bilaterally without rales, rhonchi or wheeze, with moderate air flow.
HEART:  Regular rate and rhythm, normal S1, S2, with 2/6 systolic ejection murmur, unchanged from previous, 2+ carotids without bruits.
ABDOMEN:  Slightly obese.  Suprapubic catheter is clean, dry, and intact.  No hepatosplenomegaly or CVA tenderness with bowel sounds in all 4 quadrants, 1+ femoral pulses.
BACK:  No para, supra or lateral spinal tenderness to deep palpation.
GENITOURINARY:  Deferred.
RECTAL:  Deferred.
EXTREMITIES:  No clubbing, cyanosis or edema with vascular changes of bilateral lower extremities.
NEUROLOGIC:  Cranial nerves II through XII intact.  Some difficulty following directions.  Bilaterally symmetrical muscle mass, strength and tone. Downgoing plantars.


PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 112/64 in the right arm, pulse 72 and regular, respirations 18, weight 132 pounds, temperature 98.4 degrees.
GENERAL:  The patient is a thin, well-developed (XX)-year-old female looking her stated age in no acute distress.
HEENT:  No scleral icterus or xanthelasma. Mouth:  No oral pallor or cyanosis.
NECK:  Carotid pulses are full and without bruits. Jugular venous pressure is normal.
CHEST:  Decreased breath sounds throughout.
HEART:  Cardiac impulse feels normal. There are no murmurs or gallops. The heart sounds are distant.
ABDOMEN:  No abdominal masses or bruits.
EXTREMITIES:  Peripheral pulses are full. No edema. No varicose veins.
CENTRAL NERVOUS SYSTEM:  Nonfocal.
PSYCHIATRIC:  Oriented x3.
SKIN:  Warm and dry.


PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 114/74, pulse 78, respiratory rate 21, temperature 98.4, pulse ox 98% on room air.
GENERAL:  The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
HEENT:  Atraumatic, normocephalic. Pupils equal, round, react to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. She has no pain with palpation over the globe itself. In periorbital soft tissues, she has redness and swelling present, but it is not the cellulitic redness; it is more of an irritated allergic reaction redness. Her left eye was tested. Visual acuity was tested and is 20/50. Her right eye visual acuity was 20/50 as well. She has no tenderness to palpation around her eyes. She has no purulent drainage. The oropharynx is clear. Pink and moist mucous membranes. 
NECK:  Supple, no lymphadenopathy, no thyromegaly. Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
SKIN:  Warm and dry. No evidence of rash other than is noted around the eyes.
NEUROLOGIC:  Intact. Moving all 4 extremities symmetrically and spontaneously and following commands.


PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 116/78, pulse 82, respiratory rate 18, temperature 98.4. Pulse ox is 99% on room air.
GENERAL:  The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
HEENT: Atraumatic and normocephalic. Pupils are equal, round and reactive to light. Extraocular movements are intact. Sclerae are anicteric. Conjunctivae are clear. Pharynx is grossly clear with pink, moist mucous membranes with the exception that her right tonsil is enlarged and erythematous with some exudate present. The left tonsil is not very remarkable. She has no sublingual swelling. The patient has serous fluid behind her tympanic membranes, right greater than left.
NECK:  Supple. She does have a very tender 2 x 2 cm lymph node in her right anterior cervical chain that is freely mobile. There is no surrounding cellulitis. Her trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
CARDIOVASCULAR:  Heart has regular rate and rhythm.
ABDOMEN:  Soft, nontender and nondistended.
SKIN:  Warm and dry with no evidence of rash.


PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 132/84, pulse 90, respiratory rate 18, temperature 98.4, pulse ox 100% on room air.
GENERAL:  She is awake, alert and oriented, in no apparent distress resting comfortably on the bed.
HEENT:  Atraumatic, normocephalic. Pupils are equal, round, reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Her conjunctiva on the left is clear. On the right, she has some conjunctival hemorrhage present, both medially and laterally, with some conjunctival injection as well. She has on slit-lamp examination, a negative fluorescein exam. She has no evidence of hyphema and has no evidence of retained foreign body. Oropharynx is clear with pink, moist mucous membranes.
NECK:  Supple. There is no lymphadenopathy, no thyromegaly.  Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
SKIN:  Warm and dry, no evidence of rash. She does have some periorbital ecchymosis around the right eye and a minimal amount of edema there as well, but there is no surrounding erythema, no crepitance.
NEUROLOGIC:  Intact, moving all 4 extremities symmetrically and spontaneously and is following commands.


PHYSICAL EXAMINATION:
VITAL SIGNS:  BP 108/60, temperature 98.6, pulse 82 and respirations 21.
GENERAL:  The patient is a well-developed (XX)-year-old in no distress.
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.
NECK:  Supple. No JVD. Trachea is midline. No meningeal findings.
CARDIOVASCULAR:  Regular rate and rhythm. S1 and S2. No murmurs, rubs or gallops are heard.
RESPIRATORY:  Lungs are clear to auscultation bilaterally with good air exchange.
GASTROINTESTINAL:  Abdomen is soft. Positive bowel sounds. Nontender. No masses. No rebound or guarding noted.
MUSCULOSKELETAL:  No clubbing, cyanosis or edema. Extremities are nontender to palpation.
NEUROLOGIC:  The patient is alert and oriented x3. Cranial nerves II through XII are intact. The patient has 5/5 grip strength, equal bilaterally. Normal finger to nose testing and normal gait.
SKIN:  The patient has no rashes or exanthems.


PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the ED today, temperature is 98.4, blood pressure 152/74, pulse 86, respiratory rate 16, O2 saturations 99% on room air.
GENERAL: The patient is in no acute distress. She is awake, alert and oriented x3. She is cooperative with the exam. She has a nasal tone to her voice and does appear to have significant rhinorrhea but otherwise is well appearing.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular muscles are intact. TMs are unremarkable and intact bilaterally. No evidence for infection. Nasopharynx shows bilateral boggy erythematous turbinates with a clear rhinorrhea and some left-sided maxillary sinus tenderness with a fullness sensation to her face when she leans forward. Oropharynx is clear. No erythema, exudate or lesion. She does have bilaterally enlarged tonsils, which she states is baseline for her, but no difficulty or pain with swallowing. The uvula is midline. Airway is patent. She does have some anterior chain cervical lymphadenopathy.
HEART:  Regular rate and rhythm.
LUNGS: Clear. She is breathing easily. No wheeze, crackles or rhonchi.
ABDOMEN:  Soft, obese, nontender, no flank pain or CVA tenderness bilaterally. She does have achy discomfort. She does have tenderness to deep palpation at the right low back and into the top of her gluteus muscle on that right side. She is ambulating without any difficulty.
EXTREMITIES:  Pulses are symmetric and intact.


PHYSICAL EXAMINATION:  General:  Normal appearance, in no acute distress. Vital Signs:  Blood pressure 136/72, pulse 74, weight 244 pounds. HEENT:  Unremarkable. Neck:  No cervical spine tenderness with normal range of motion. Negative Spurling test. Heart:  Regular rhythm. No murmur. Lungs:  Clear with no wheeze or rales. Abdomen:  No tenderness. Skin:  No rash. Extremities:  No finger cyanosis or leg edema. Hand exam showed no tenderness or swelling at the IPs, MCPs or wrist. Right elbow exam showed lateral epicondyle tenderness but no joint tenderness, no swelling, normal flexion and extension. Left elbow exam was unremarkable. Shoulder exam showed no subacromial, AC or supraspinatus tenderness, normal range of motion, wrists and rotator cuffs intact. Hip exam was unremarkable. Knee exam showed no tenderness or swelling. Normal flexion and extension. Ankle and foot exam was normal. Lower back exam was unremarkable. Exam showed slight kyphosis. Neurologic exam:  Nonfocal.


PHYSICAL EXAMINATION:
VITAL SIGNS:  Upon my initial evaluation, the patient is afebrile.  Pulse 78, respirations 21 and blood pressure 118/78.
GENERAL:  The patient is a (XX)-year-old male appearing his stated age.  He is alert and interactive, in no apparent distress.  He is disoriented.
HEENT:  Head is normocephalic and atraumatic.  Extraocular muscle movements appear intact.  There is no scleral icterus.  Oropharynx is clear.  Head and neck are free of adenopathy.
HEART:  Irregularly irregular.  There may be a rub and murmur, but it is somewhat difficult to discern from the additional heart murmur that is generated by the presence of an AV fistula.
LUNGS:  Rare basilar crackle bilaterally.  No wheeze.  Percussion is normal.
ABDOMEN:  Positive bowel sounds, soft, nontender, nondistended.  No rebound, rigidity or guarding.
EXTREMITIES:  Lower extremities are without clubbing.  There is some edema.  There does appear to be a Charcot-type foot bilaterally with the right being worse than the left.  There is minimal eschar at the plantar aspect of the right foot.
NEUROLOGICAL:  Appears to move all extremities and this exam is only pertinent for confusion at this time.


PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4 degrees, pulse 84, respirations 21, blood pressure 112/88, oxygen saturation 100% on room air.
GENERAL:  The patient is mildly distressed secondary to pain. He is active, alert, oriented x3.
SKIN:  Warm to palpation, mildly dry. Color is good.
HEENT:  Head is normocephalic without any evidence of any injury. Pupils are equal, round and reactive to light and accommodation. Extraocular muscles are intact. His mucosal membranes are moist and pink with oropharynx without exudate and without erythema. His dentition is intact. No oral lesions.
NECK: His neck shows the cervical region to be without injury. The trachea is midline and no mass is palpated in the neck. The thyroid is normal to palpation.
HEART:  S1 and S2 is intact with regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally. Breathing is not labored. No wheezing, rales or rhonchi.
ABDOMEN:  Mildly distended but soft. Negative for fluid movement. No hepatosplenomegaly. No mass is palpated. Good bowel sounds x4 abdominal quadrants. 
EXTREMITIES:  There is positive edema present in the lower extremities, +2 to 3 pitting edema in the left lower extremity. There is edema in the right lower extremity but unable to fully evaluate due to bandage wrap. No clubbing or cyanosis. Pulses intact in the right lower extremity. Pulse is diminished in the left lower extremity.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Unable to assess reflexes at this time.                





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