Medical Transcription Physical Examination Words / Terms & Phrases for MTs:
VITAL SIGNS: Blood pressure 126/94, pulse 66, respiratory rate 22, and temperature 98.5.
GENERAL APPEARANCE: The patient is a (XX)-year-old female lying comfortably in bed and is paralyzed from the waist down.
HEENT: Cushingoid facies. Alopecia on her scalp seems to have resolved. No ulcers or sores in the mouth or in the nose. No tenderness on palpation over the temporal artery.
LUNGS: Bilateral breath sounds.
HEART: S1 and S2.
EXTREMITIES: No edema.
MUSCULOSKELETAL: The patient has somewhat limited range of motion of her shoulders, elbows, hips, and knees, primarily due to previous paralysis, with basically no motor power in the lower extremities. She does respond to sensory stimuli. No active synovitis in hands, wrists, and feet.
NEUROLOGIC: Alert and oriented.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient is febrile up to almost 102. HEENT: Shows no icterus. No petechiae. Pupils are reactive to light and accommodation. Conjunctivae and sclerae are normal. The nose is normal. No ulcerations. No dryness in the mouth. There is no mucositis. No yeast patches. No herpetic sores. The throat shows no abnormalities. NECK: Supple. No neck vein distention. Carotid pulses are normal. The neck veins are flat. CHEST: The chest is symmetric. LUNGS: Clear to auscultation and percussion. No wheezes. No rhonchi. There are just decreased breath sounds in the bases. HEART: Tachycardic, regular, and rhythmic. No murmurs or gallops are auscultated. ABDOMEN: Soft. There is no hepatosplenomegaly. The bowel sounds are active. There is no CVA tenderness. The external genitalia are normal. EXTREMITIES: The extremities show no peripheral edema. No muscle tenderness. No arthritis. No phlebitis. SKIN: The skin shows no new lesions. No ecchymosis. No petechial rash. The skin has the Ommaya reservoir in the frontal area which is well healed with no signs of infection. There is also a Port-A-Cath in the left subclavian area which is not red, hard, or swollen at the present time. NEUROLOGIC: The neurological exam is unremarkable. She is alert, oriented. No neurological changes. No cranial nerve involvement.
PHYSICAL EXAMINATION: Temperature 98.6, blood pressure 158/96, oxygen saturation 98%, and heart rate 90. General: He is alert and oriented x3, in moderate acute distress secondary to pain. HEENT: Within normal limits. Chest: No respiratory distress. Normal breath sounds bilaterally. Heart: Regular rate and rhythm. No murmurs, rubs or gallops. Abdomen: Nontender. No organomegaly. Normal bowel sounds. Extremities: Upper extremity exam of the left hand showed hypothenar volar aspect with superficial swelling and a white fluctuant area that is very painful to palpation. He also had some pain with passive motion of the small finger and ring finger. He had no pain with passive motion of his middle, index or thumb. No pain with active motion of his wrist. He has an erythematous painful swelling with draining pustule on the hypothenar eminence. He has 2+ radial pulse on that side and brisk capillary refill. Neurological: General neuro exam is within normal limits. He is oriented x3, appropriate mood and affect.
PHYSICAL EXAMINATION: On the day of discharge, T-max was 98.4, respiratory rate ranged between 22 to 24, pulse was 62 to 92, blood pressure 112/52. General: The patient is tired and appears sleepy but when told is going home becomes awake and alert and discusses how eager he is to go home. Does have a sudden outburst of knee pain. HEENT: Normocephalic, atraumatic. Does have acanthosis nigricans on the neck. Oropharynx is clear. Moist mucous membranes. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm with murmur, 2+ pulses. Abdomen is soft, obese, nontender, nondistended. Positive bowel sounds. Positive striae. Difficult to palpate spleen secondary to obesity. Extremities: Warm, well perfused. No clubbing, cyanosis or edema. Knees are noted to not be edematous without effusion and nonerythematous bilaterally with normal range of motion. Negative anterior drawer. Does have pain upon palpation of the patella bilaterally. Neurologically, the patient is able to ambulate well. Has normal tone and although cognitively appears slow was able to respond to questions.
PHYSICAL EXAMINATION: He is 5 feet 6 inches, 220 pounds. Well-nourished, well-developed gentleman in no acute distress. Normal affect. Skin is intact. He has what sounds like improved swelling. He has a little bit of swelling about the knee, but nothing overly significant. He has a little recurvatum bilaterally, which is symmetric. He can flex up to 90 at this point; beyond 90, had a little bit of soreness medially. Really, the only place today on my exam that is sore is over the adductor tubercle, medial epicondyle region consistent with an MPFL injury. He really has no pain or apprehension with medial lateral glide of the patella. His Q angle was approximately 10-15 degrees today. He has a negative Lachman, negative varus valgus stress. He does not really have significant joint line soreness today. He is otherwise grossly neurovascularly intact.
PHYSICAL EXAMINATION: Well-developed, well-nourished woman, in no acute distress. Blood pressure 132/82. Pulse 82 and regular. Height 64 inches. Weight 144 pounds. Pain score 0. Conjunctivae were within normal limits. The left tympanic membrane was distorted and scarred with some centralized erythema. The right tympanic membrane and both auditory canals were within normal limits. The nasal mucosa was boggy. Nasal septum was within normal limits. The oropharynx was clear. Neck examination revealed soft movable anterior nodes. There were no palpable thyroid masses. The lungs were clear and heart examination at the base was within normal limits. Skin was generally dry. There were scattered fine maculopapular lesions on her forearms with some excoriations.
PHYSICAL EXAMINATION: Well-nourished, well-developed gentleman, in no acute distress. Normal affect. Skin is intact. He has normal gait. He is able to toe and heel walk. He has a little bit of swelling around the Achilles tendon, nothing overly significant. He has tenderness to palpation a few centimeters up from the Achilles insertion. He has a little bit of pain over the plantar fascia as well. He has maybe a little bit of tightness with dorsiflexion but has 5/5 dorsiflexion, plantar flexion, EHL function. Sensation is intact throughout as well and he has a normal Thompson maneuver.
PHYSICAL EXAMINATION: When he presented to the hospital, his temperature was 98.6. Pulse was 104. Respirations 18. Blood pressure 104/72. Weight is 82 kg. O2 saturation 96%. Head is normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Oral mucosa is moist. No JVD. No thyromegaly. No carotid bruits. Lungs: Essentially a few scattered rhonchi. Heart is tachy rate and rhythm. S1 and S2. No S3, S4. Abdomen was distended, tender on the left side with some guarding and some decreased bowel sounds. Had a rectal exam that was heme positive. Back: No CVA tenderness. Skin is warm and dry. No rash. Extremities: No clubbing, cyanosis or edema. Good pedal pulses bilaterally. Deep tendon reflexes appear grossly intact, 2/4 upper extremity and lower extremity bilaterally. Neurologic: Cranial nerves II through XII were intact.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient’s blood pressure is 108/69, pulse 72, respiratory rate 24, and temperature is 98.5. GENERAL APPEARANCE: The patient is an (XX)-year-old gentleman in no acute distress, on oxygen. HEENT: Pupils are equal, round, reactive to light and accommodation. Extraocular muscles intact. No tenderness on palpation over the temporal arteries. CHEST: Bilateral breath sounds. HEART: S1 and S2. ABDOMEN: Soft. EXTREMITIES: No edema and no cyanosis in the lower extremities. In the upper extremities, the right wrist joint has obvious swelling and also redness and increased temperature. The patient is unable to move the right upper extremity freely because of the discomfort in his wrist joint. Left shoulder seems to be moving fine. Elbow joint appears to be fine. Limited range of motion on the right shoulder joint secondary to pain in his right wrist and his inability to move the arm freely. The right wrist joint is warm with an effusion. The temperature is increased. There is redness. Hip movements are fine. Minimal crepitus in the knee joints and his feet. There is no tenderness on palpation over the MTP joints. Motor power appears to be good in the left upper extremity and the lower extremities. NEUROLOGIC: Neurologically, the patient is alert and oriented.
PHYSICAL EXAMINATION: He is afebrile with a pulse of 102, blood pressure 126/88, respiratory rate of 20-22 and O2 saturation of 98% on room air. This is a pleasant, well-developed, overweight gentleman who was in no apparent distress but mildly tachypneic. He is able to speak full sentences. He weighed 130 kg. HEENT: Shows anicteric sclerae. He has Mallampati class IV airway. Neck exam shows no stridor. There is no lymphadenopathy. Lung exam was notable for some intermittent audible wheezing. There seemed to be some end-expiratory wheeze. He has no accessory muscle use. He clearly has a hard time when he tries to be supine. Cardiac exam shows an irregular rhythm, but no murmurs or rubs. Abdomen was protuberant. There is normal bowel sounds. Abdomen is soft. Extremity exam shows 2+ edema. There is mottling over both forearms as well as at the flanks bilaterally. Neurological exam was limited but essentially nonfocal.
PHYSICAL EXAMINATION: The patient is a well-nourished female in no acute distress, pleasant, cooperative. Neurovascularly intact to sensation and motor. She has full range of motion of shoulder, elbow, wrist, and digits. She has positive Hawkins, positive Neer. Cuff is intact.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: This is a pleasant (XX)-year-old female presently in no acute distress. The patient is alert and oriented x3, pleasant, and cooperative with the examination. Height is 5 feet and 6 inches, weight 146 pounds, blood pressure 110/64, heart rate 52 and regular, and respirations are 16. SKIN: Warm and dry. HEENT: Head is normocephalic. Eyes: Pupils are equal and reactive. ENT: Unremarkable. Tongue is midline. Mucosa is moist. NECK: Supple. No JVD. No lymphadenopathy. No carotid bruits. LUNGS: Clear with no rales, wheezes, or rhonchi. HEART: Reveals regular rhythm/bradycardic rhythm. S1 and S2 intact. There is a soft grade 1/6 systolic murmur noted along the left sternal border. CHEST: Sternotomy scar is well healed. ABDOMEN: Soft and nontender. Positive bowel sounds. EXTREMITIES: Free of edema, cyanosis, or clubbing. Pulses reveal 2+ radial pulses. Femoral pulses are 2 to 3+ bilaterally with no femoral bruits. Dorsalis pedis pulses 1+ bilaterally. Muscles, bones and joints are unremarkable. NEUROLOGIC: Memory function is intact. RECTAL: Deferred. PELVIC: Deferred.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a middle-aged female, not in any acute distress, appeared comfortable with vital signs of blood pressure 132/74, pulse 76, respiratory rate 22, and temperature is 97.4. HEENT: Head is atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. Sclerae clear. Lips not cyanotic. Palate normal. Pharynx is normal. Tonsils not enlarged. Buccal mucosa without any pigmentation. Tongue and mouth, dry. Neck supple. Negative JVD. Trachea is central. Thyroid is not enlarged. CHEST: Normal expansion. No crepitation. No fremitus. No tenderness on palpation. Bilateral air movement with no wheezing. No rhonchi. No dullness to percussion. No use of accessory muscles. No intercostal muscle retraction. Basilar crackles. HEART: Regular rate and rhythm. S1 normal. S2 physiologic split. Negative S3. No prominent P2. No murmur appreciated. ABDOMEN: Obese, soft, and nontender. Bowel sounds are positive. No organomegaly. EXTREMITIES: Negative cyanosis. Negative clubbing. Trace edema. Positive pulses. NEUROLOGIC: Neurologic examination is intact. RECTAL/PELVIC/BREASTS: Exam deferred. SKIN: Without any rashes.
PHYSICAL EXAMINATION: The patient is a well-developed, mildly obese male who appears to be in no acute distress. Blood pressure 108/72, heart rate 102, and T-max 102. HEENT: Head is normocephalic. Neck: Soft and supple. Thyroid is midline and nonnodular. No carotid bruits are noted on auscultation. Lungs: Clear to auscultation throughout and somewhat diminished in the left base, with mild bronchovesicular breath sounds in the lower left fields. Respirations are unlabored at present. Heart: Rhythmic and regular without any murmurs, gallops or rubs. There is no jugular venous distention. No hepatojugular reflux. The PMI is nondisplaced. Abdomen is 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. Peripheral Vascular: Dorsalis pedal pulses and posterior tibial pulses are intact bilaterally, and there is no pitting or pedal edema.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: This is an (XX)-year-old gentleman who appears to be answering appropriately and appears to be alert to place and person. VITAL SIGNS: Blood pressure 126/59, heart rate 84, respirations 22, temperature 97.6, saturation 94% on 1 liter via nasal cannula. HEENT: Pupils are round and reactive to light equally. There is evidence of ocular lens implantation bilaterally. Teeth are in poor repair. Uvula is midline and tongue appears slightly pink and dry. NECK: Supple. No thyromegaly noted. There is some jugular vein distension bilaterally noted. No carotid bruits. LUNGS: Clear and diminished bilaterally. There are a few mild expiratory rhonchi noted. HEART: There is a 2-3 out of 6 systolic murmur best heard in the right sternal border. ABDOMEN: Soft and nontender with positive bowel sounds. I cannot appreciate any abdominal bruits or masses. EXTREMITIES: No evidence of peripheral edema. There is some bronzing of the skin bilaterally; however, pedal pulses are 2+ bilaterally. There is no peripheral edema. NEUROLOGIC: Neurologically, there are no focal deficits noted.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient's vital signs on admission; temperature 100.6 degrees, pulse 104, respirations 40, blood pressure 146/86, pulse oximetry 96% on 2 liters oxygen. SKIN: Warm and dry. HEENT: Head was normocephalic and atraumatic. Extraocular muscles were intact. No scleral icterus. No throat erythema or exudates. NECK: Supple. No lymphadenopathy. Mild JVD with hepatojugular reflex. LUNGS: Bibasilar rales were noted. No wheezes or rhonchi. HEART: S1 and S2 present and tachycardic 2/6 systolic murmur noted on the left upper sternal border, more pronounced in the mitral valve area. No rubs or gallops. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. GENITAL AND RECTAL: Deferred. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient was awake, alert, and oriented x3. Cranial nerves II through XII are grossly intact. Sensation was intact. Motor strength was 5/5.
PHYSICAL EXAMINATION: The patient’s pulse was 73, respirations were 20, and blood pressure was 194/100. O2 saturation was 98%. In general, the patient was in no apparent distress. Skin. No rashes or lesions. Head was normocephalic, atraumatic. Pupils were equally round and reactive to light. Throat was clear. Neck: Mild JVD. No lymphadenopathy. Chest: Nontender. Heart: S1, S2 present. No murmurs, rubs or gallops. Lungs were clear to auscultation. Abdomen was soft, nontender, nondistended. Bowel sounds were present. Genital and rectal examinations were deferred. Musculoskeletal: No joint pain or point tenderness. Extremities: No clubbing or cyanosis. Trace pedal edema bilaterally. Neurologically, the patient’s cranial nerves II through XII are grossly intact. No focal deficits. Deep tendon reflexes were 2+.
PHYSICAL EXAMINATION: Her height is 64-1/2 inches, 50th percentile. Weight is 114 pounds, up 7 pounds, 25th percentile. Blood pressure is 110/70. BMI is 19.3, up from 17.8 last year, 21st percentile. She is a well-nourished, well-developed female in no acute distress. Normocephalic, atraumatic. TMs normal bilaterally. Pupils are equal and reactive to light. Extraocular muscles are intact. Red reflex bilaterally. Throat: Negative. Neck: Negative. Lungs: Clear to auscultation. Heart: Regular rate and rhythm. Breasts: Tanner V. No masses bilaterally. Abdomen: Soft, positive bowel sounds. No hepatosplenomegaly. Pelvic exam was deferred. Neurologic: Cranial nerves are intact, nonfocal.
PHYSICAL EXAMINATION: Height 62-1/4 inches, 25-50th percentile. Weight 154 pounds, 90-95th percentile. BMI is 27.9, more than 95th percentile. Blood pressure is 110/66. General Appearance: The patient is healthy looking but overweight, is pleasant and interactive. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose: Clear. Nasal turbinates are not swollen. Throat is clear. Mouth is clear. There is no neck mass. Chest/Lungs: Good air entry with clear breath sounds. Heart: Normal first and second heart sounds, regular rhythm, no murmurs. Breasts: Tanner IV, symmetric. No mass. Both nipples everted. There is axillary hair and axillary odor. Spine: Straight. Abdomen: Soft, flat, no tenderness. External genitalia normal. Pelvic examination was deferred. Extremities: No deformity. Full range of motion. No swelling of the joints. There is no pedal edema. Skin: Clear. Neurologic: Normal.
PHYSICAL EXAMINATION: Height 66-3/8 inches, 20th percentile; weight 141 pounds, 50th percentile; blood pressure 120/60; heart rate 78 per minute, sitting. General Appearance: This young man appears to be a well-nourished, well-developed male. HEENT: Eyes: Positive red reflex. Disks clear and sharp. EOMI. Pupils are equal, round and reactive to light and accommodation. Nose: Clear. Throat: Clear. Ears: TMs clear bilaterally. Neck: Supple, no thyromegaly. Chest: Clear to A and P. Spine: No scoliosis. Abdomen: Soft, no masses. Bowel sounds present. External Genitalia: Tanner IV. Testes descended bilaterally, normal male, normal scrotum. Extremities: Good femoral pulses, +2 bilaterally. Skin: Normal. Neurologic: No focal deficits.
PHYSICAL EXAMINATION: General: Morbidly obese female sitting in exam chair, in no obvious distress. Vital Signs: Pulse 72, respirations 18, blood pressure 122/74. Height 5 feet 4 inches and weight 276 pounds. HEENT: Pupils are equal, round and reactive to light and accommodation. Sclerae anicteric. Oral cavity moist and pink. Tongue protrudes midline, 1+ to 2+ tonsillar hypertrophy without crypt exudate or obstruction. Neck: Supple. No JVD, adenopathy or thyromegaly. Lungs: Clear to bases bilaterally. Heart: Regular rate and rhythm. No S3, S4, murmur or carotid bruits. Abdomen: Centrally obese. Distant bowel sounds in all quadrants. Organomegaly not appreciated secondary to body habitus. No tenderness, masses, rebound. Peripheral Vascular: Extremities warm and dry without edema. Musculoskeletal: Muscle strength 5/5, all major muscles. Neurologic: Motor strength 5/5, all major muscles. Sensation intact to light touch of all the major dermatomes. Gait steady.
PHYSICAL EXAMINATION: Her height is 33-1/4 inches, 75th percentile. Weight is 25 pounds, which is up, which is the 49th percentile. Head circumference is 18-1/2, 53rd percentile. She is a well-nourished, well-developed female in no acute distress. Normocephalic, atraumatic. TMs normal bilaterally. Pupils are equal and reactive to light. Positive red reflex. Accessory muscles intact. Neck: Negative. Chest: Tanner I. Lungs: Clear to auscultation. Heart: Regular rate and rhythm without murmur. Abdomen: Soft, positive bowel sounds. No hepatosplenomegaly. Extremities: Within normal limits. Skin: Did have initially a glabellar salmon patch, but that is fading. Neurologic: She is very alert. DTRs are equal. Cranial nerves are intact, nonfocal.
PHYSICAL EXAMINATION: In general, this is a well-developed, overweight, confrontational male who appeared to be somewhat agitated and frustrated. He had a blood pressure of 122/84, pulse of 68, respirations of 18. He had very significant pain behavior. He appeared very distracted and had a blunt affect with a depressed mood. He had very poor eye contact. On structural exam, the patient had a thoracolumbar scoliosis, which is compensated. He had protraction of the neck and shoulders with postural syndrome. He had decreased range of motion in all planes of the cervical, thoracic, lumbar regions including the shoulders due to significant kinesophobia and guarding. He had multiple trigger points throughout the cervical and thoracolumbar fascia. He had generalized tenderness throughout the axial spine, however, nonfocal. There was no step-off deformity. Distal vasculature is otherwise intact and symmetric. He had multiple skin abrasions, which were all chronic. He did not have any tract signs on his arms. There was tenderness over the sacroiliac joint region, however, nonfocal. Sacroiliac provocation tests were equivocal. Neurologic exam of the upper and lower extremities; intact to motor power. This included intrinsic hand as well as intrinsic shoulder musculature. Sensory exam is intact to light touch in all dermatomes. Reflexes were +1 and symmetric in the bilateral upper and lower extremities. There is no evidence of myelopathy. Lhermitte sign was negative. Spurling's was negative. Axial compression was positive for neck and low back pain. Finger-to-nose was intact and Romberg was negative. He was able to get up from a seated position using two-legged stance. He is able to squat on his knees. His gait was nonantalgic.
PHYSICAL EXAMINATION: She is a pleasant female who presents well, in no acute distress. Her height is 5 feet 4 inches, weight 166 pounds, and blood pressure 122/84. She rates her pain as 0 on a scale of 1-10. Her lymph node survey is unremarkable. No supraclavicular, axillary or inguinal nodes palpated. Her breast exam in the supine position revealed no masses, no lumps, and no nipple discharge. Abdomen: Soft, nontender to palpation. No hepatosplenomegaly or masses palpated. Her pelvic exam revealed normal female external genitalia, urethra and vagina. Her skin was intact with no lesions noted. Vaginal vault was free of bleeding and discharge. Cervix was well visualized, smooth with no CMT. ThinPrep Pap was obtained. Cervix was slightly stenotic. Bimanual exam revealed no masses and no tenderness. Adnexa negative. On rectovaginal exam, no masses and no tenderness.
PHYSICAL EXAMINATION: Height 5 feet 4 inches. Weight 162 pounds. Vital Signs: Blood pressure 126/64, pulse 78. HEENT: Pupils equal and reactive to light. Tympanic membranes are normal. There is some cerumen in the right canal, which was syringed and removed. Throat is normal. Carotids: No bruits. Thyroid not enlarged. Lungs: Clear. Breasts: Negative. Heart: Regular rhythm. No murmurs. Abdomen: Soft, no tenderness, no masses. Bimanual/Pelvic: Normal uterus. Ovaries not enlarged. Rectal: Brown stool, guaiac-negative. Extremities: Good DP pulses, no edema. DTRs are hypoactive.
PHYSICAL EXAMINATION: His blood pressure today is 136/80. Height is 5 feet 8 inches. Weight is 180. His cardiac examination shows normal sinus rhythm. There still is a grade 1/6 systolic murmur down the left sternal border, but no cardiomegaly. The lungs are clear without rales. He has no pedal edema. He still has a minute Dupuytren's contractures of both hands, but they are not tightening up and as long as he can extend his fingers I see no problem. He shows some minor limitation of his right hip on internal and external rotation. His left shoulder also is tight on external rotation. I feel no hernia. Prostate exam shows a small soft prostate without nodularity. His peripheral pulses are excellent. The right is bounding at +2. The left is only slightly less forceful. Carotids are +2 without bruits.
PHYSICAL EXAMINATION: On exam, she is an obese woman who looks approximately her stated age and does not appear to be in any acute distress. Vital signs include a blood pressure of 132/96, pulse of 102, height of 66 inches, weight of 270 pounds. HEENT: She is normocephalic. PERRLA. EOMs intact. She wears corrective lenses. Mucous membranes are moist. Tongue and nasal septum appear to be in the midline. Her sclerae are anicteric. Her tongue and nasal septum appear to be in the midline. Neck is obese with no discernible lymphadenopathy or thyromegaly. She has no carotid bruits. Her chest is clear to auscultation bilaterally. She appears to have full and symmetric expansion and excursion and a normal respiratory effort. Heart: She has no murmurs, no gallops that are discernible. S1 and S2 appear to be normal. Abdomen is obese with a gynoid pattern of obesity. She has a grade 1 to 2 pannus. There are no surgical scars. She has no evidence of abdominal wall hernias. Her abdomen is nontender with no discernible hepatomegaly or splenomegaly. In addition, she does not appear to have any abdominal masses. However, her abdominal exam is somewhat limited because of her obesity. Lymphatic: She has got no discernible cervical, axillary or inguinal lymphadenopathy. Musculoskeletal: She ambulates without assistance and her gait appears to be grossly normal. Extremities: There is no evidence of clubbing, cyanosis or edema on her lower extremities. Skin: There is no evidence of current rashes or ulcerations. Neurologic: She is awake, alert, and oriented.
PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished woman, in no acute distress. She has no evidence of scleral icterus. She has no evidence of supraclavicular, cervical or axillary adenopathy bilaterally. Her pupils are equally round and reactive to light. Her extraocular movements are intact. Her neck is supple. Her mucous membranes are moist. Her lungs are clear to auscultation bilaterally. Her heart is regular rate and rhythm. She has no evidence of spinal tenderness. Her abdomen is soft and nontender without evidence of hepatosplenomegaly. Her extremities are without clubbing, cyanosis or edema. Neurologically, she is alert and oriented x3. Her breasts are moderately large, pendulous, and slightly asymmetric. Her right breast is smaller than the left. She has a well-healed superior circumareolar incision that does not cause any skin retraction or defect. She has no evidence of nipple discharge, nipple retraction or other skin changes bilaterally. I could not appreciate any concerning dominant masses in either breast.
PHYSICAL EXAMINATION: On physical exam, the patient is an alert and oriented woman, in no acute distress. Neck is supple without masses. There is no thyromegaly. There is no cervical, supraclavicular or axillary adenopathy. Lung sounds are clear to auscultation. Cardiac exam reveals regular rate, S1 and S2, without any evidence of murmur, rub or gallop. Skin overlying the breasts reveals well-healed surgical incisions in the 6 o'clock position of the breast. There are telangiectases at the surgical scar. Otherwise, skin is intact without dimpling or puckering. Nipples are everted and without discharge. Examination of the right breast reveals surgical and radiation changes of the breast with no discrete mass or lump. Examination of the left breast reveals no dominant mass or lump. Abdomen: Soft and nontender. There is no hepatosplenomegaly. There is no tenderness of vertebral spine. There is no bony tenderness of the vertebral spine. There is no significant evidence of peripheral edema in the upper extremities.
PHYSICAL EXAMINATION: On physical exam, her weight is 142 pounds, height 5 feet 8 inches, blood pressure 156/74, temperature 96.4, pulse 76, O2 saturation 98% on room air. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx: Without erythema or exudate. Neck: Supple, no lymphadenopathy, no thyromegaly. Chest: Clear to auscultation. Heart: S1, S2. Rate and rhythm are regular. No murmurs, gallops or rubs. Abdomen: Soft, nontender, normal bowel sounds. No hepatosplenomegaly. Extremities: Without edema. Distal pulses 2+ bilaterally. Breasts: No masses, skin changes, nipple discharge or axillary lymphadenopathy. Examination of the right shoulder shows that she has limitation of flexion at about 120 degrees. She has a lot of crepitus in that shoulder and that shoulder seems to be sitting a little bit lower than the left shoulder. She has some pain with internal rotation as well.
PHYSICAL EXAMINATION: Blood pressure 112/66, heart rate 66, respiratory rate 18, and weight 128 pounds. She currently denies pain. She is nicely attired and groomed, pleasant and cooperative. She ambulates with a cane safely. The lungs are clear bilaterally. Cardiac examination reveals a regular rate and rhythm with a normal S1 and S2 and no murmur. There are no carotid or cranial bruits noted. Neurologically, she is oriented to place. She is unable to tell me the month and is uncertain about the year. She reports that we are in the spring season. She is not able to discuss any current events, although she states that she does pay attention to the news. She is able to register 3/3 objects easily, but can recall none of them spontaneously at 3 minutes. With prompting, she can recall one of them. She performs serial 7s a little bit slowly, but well. She is able to perform simple calculations. She can copy intersecting pentagons, but not a cube. She is able to draw a clock correctly with the hands placed at the time requested. She can follow a three-step command. She is able to name, repeat, read, and write. Cranial nerve examination reveals small pupils bilaterally, which are reactive to light. I cannot get a good look at her fundi today. Her saccades are a bit jerky with square wave jerks. There is no nystagmus. I cannot get her to accommodate. Visual fields are full. The face is symmetric in movement and sensation. Hearing is grossly diminished to conversation bilaterally. The palate elevates symmetrically. The tongue is midline and agile. Shoulder shrug is equal. There is no pronator drift. She has 4+/5 strength in the deltoids bilaterally. Iliopsoas is 4+/5 bilaterally. Otherwise, strength is full throughout. Motor tone is normal. There are no frontal motor release signs. Deep tendon reflexes are 2+ symmetrically at the knees, 1+ symmetrically in the upper extremities. I cannot elicit ankle jerks. She has withdrawal bilaterally to plantar testing. Sensory examination is notable for diminished pinprick and vibration in the distal stocking distributions bilaterally. Temperature sensation and joint position sense are well preserved. There is no extinction to double simultaneous stimulation. Finger-to-nose testing reveals no dysmetria. She has a positive Romberg sign. She can take a few steps on her toes and heels. She has difficulty tandem walking. Relaxed gait is done with a cane. She is unsteady and has some scoliosis, tending to lean her trunk towards the left.
PHYSICAL EXAMINATION: The patient is a very pleasant (XX)-year-old female. The patient appears younger than her stated age. She is 5 feet 4 inches and 160 pounds. Out of the boot, her foot is very macerated over the medial heel and over the metatarsal heads, plantar aspect. The blisters are just below the medial malleolus. It is very superficial and it is ruptured. There is no drainage or erythema around this. She has no pain to palpation over the malleoli. Mildly tender over her deltoid. No ecchymosis there. There is some very mild swelling. Her posterior tib tendon is nontender with palpation. However, her inversion strength is 4-/5 as compared to the right.
PHYSICAL EXAMINATION: On examination today, blood pressure is 120/62, pulse is 74, respirations are 18. She is awake and more alert than usual. She can smile and stick out her tongue. She shows me the left olecranon region where there is ecchymosis. There is no erythema or warmth or significant edema. She was able to touch her chin to her chest. She was able to abduct her right upper extremity. She did lift her left upper extremity somewhat, but for the most part, plegic. She ambulated for several steps but has an uneven, somewhat spastic gait, particularly on the left side. Left lower extremity demonstrates some atrophy compared to the right side. Right upper extremity reflexes are 3+. Left upper extremity reflexes are difficult to obtain secondary to the patient’s injury. Patellar reflexes 2+ bilaterally. Ankle reflexes are 2+ bilaterally.
PHYSICAL EXAMINATION: Vital signs include a blood pressure of 142/82, pulse of 84, respiratory rate of 18, height 72 inches, and weight of 172 pounds. HEENT: Normocephalic. Pupils are equal, round and reactive to light and accommodation. EOMs grossly intact. He wears corrective lenses. Mucous membranes are moist. Tongue and nasal septum appear to be in the midline. Neck is supple with no lymphadenopathy and no thyromegaly appreciable. Chest is clear to auscultation bilaterally. Heart: No murmurs, no gallops. Abdomen is flat, soft, nontender. No hepatomegaly, no splenomegaly, and no abdominal masses are appreciable. His external genitalia are those of a normal circumcised male with no testicular masses. He has an easily discernible left inguinal hernia, which is easily reducible. He has no evidence of a hernia on the right. His extremities are symmetric with no evidence of clubbing, cyanosis or edema. Musculoskeletal: He ambulates without assistance and his gait appears to be grossly normal. Neurologic: He is awake, alert, and oriented x3.
PHYSICAL EXAMINATION: Blood pressure 112/72, pulse 64, respirations 18. She has mild facial masking and speech is still slightly dysarthric. She has no dyskinesias. She has minimal right hand resting and posture tremor, which disappeared after stimulation adjustment. She had some bradykinesia rated as 1 on UPDRS score in the right hand, but I do not appreciate any rigidity or bradykinesia on the left side or the right lower extremity. She still continues to have mild dystonic posturing in the right lower extremity. She walks with dragging of the right foot.
PHYSICAL EXAMINATION: Vital Signs: Heart rate 72, blood pressure 132/80, and respiratory rate 16. General: He is a pleasant male in no acute distress. HEENT: Normocephalic. No nuchal rigidity. Cardiovascular: Normal S1, S2, regular rate and rhythm. No carotid bruits. Lungs: Clear to auscultation bilaterally. Neurologic: Mental Status: He is alert and oriented x3. He has fluent language with intact comprehension. There is no left/right confusion, neglect or apraxia. Recent and remote memory intact. Cranial Nerves: Pupils are equal, round, and reactive to light. Funduscopy is negative for papilledema. Extraocular movements are intact without nystagmus. Visual fields are full to confrontation. Face is symmetric with full strength and sensation. Hearing is conversationally intact. Palate elevates symmetrically. No dysarthria. Sternocleidomastoid and trapezius, full strength. Tongue protrudes midline. Motor exam: Normal tone and bulk, 5/5 strength in all extremities. No pronator drift. Reflexes: 2+ in the upper and lower extremities. Plantar response is mute. Sensory: He has mild early extinction to vibration in bilateral toes. He also has a slight difficulty with proprioception in the toes. Sensation is intact to light touch, temperature, and pinprick throughout. Coordination: No dysmetria on finger-to-nose, heel-to-shin, rapid alternating movements. Gait: He has a steady, narrow -based gait. He is able to toe walk, heel walk and do tandem gait without difficulty. Romberg is negative.
PHYSICAL EXAMINATION: Normal appearance, in no acute distress. HEENT: Unremarkable. Heart: Regular rate and rhythm. Lungs: Clear with no wheeze or rub. Abdomen: No tenderness. Hand Exam: No tenderness or swelling at the IPs, MCPs, and wrists. Elbow Exam: Unremarkable. Shoulder Exam: Slight tenderness on range of motion. Hip Exam: Slight tenderness on range of motion with borderline stress test on SI joints. Knee Exam: No tenderness or swelling with normal flexion and extension. Ankle Exam: Shows laxity on inversion, but no joint line tenderness. Lower Back Exam: Shows slight lumbosacral and sacroiliac tenderness.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.5, heart rate 72, respiratory rate 20, blood pressure 124/82, and O2 saturation 100% on nasal cannula. GENERAL: The patient is awake. He is extremely anxious and agitated. He is trying to get off the backboard and is swearing and uncooperative at times. SKIN: Multiple facial lacerations and a lip laceration. HEENT: Pupils are equal and round and reactive. I am unable to get the patient to cooperate with movement of the extraocular muscles to look for any sign of entrapment. Examination of the oropharynx is difficult as the patient is noncooperative, but I do not notice any broken teeth. There is a laceration noted to the right upper lip. This is very small, measuring only 0.5 cm in length. There does not appear to be any significant injury to the interior of the mouth. Nose is somewhat swollen. There is blood noted in the bilateral nares. Examination of the face reveals swelling over the right eye and of the right face. There is tenderness throughout this region. A cervical collar is in place. The patient is noted to have no step-off or deformity, but he is unable to cooperate with examination so cervical collar was left in place. BACK: The patient is noted to have scrapes and bruising to the right upper back and thorax region. MUSCULOSKELETAL: The patient was rolled on his side in cervical spine precautions and he was not noted to have any deformity or step-off in the back, but told me he had tenderness throughout the entire back. HEART: Regular rate and rhythm. LUNGS: Clear and equal bilaterally. ABDOMEN: Soft and nondistended. No hepatosplenomegaly. EXTREMITIES: The patient is moving all extremities with no obvious deformities. PELVIS: Appears to be stable. NEUROLOGICAL: There appears to be no focal deficits, although the patient again is uncooperative with full examination.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.8, pulse 88, respirations 18, and blood pressure 134/86. Height is 5 feet 7 inches. Weight is 154 pounds. Room air saturation is 96%. GENERAL APPEARANCE: The patient is a (XX)-year-old male. Well developed and well nourished. HEENT: Normocephalic and atraumatic. Pupils were equal, round, and reactive to light, and accommodation. EOMI. Visual fields were full. Conjunctivae were clear. Ears: Canals were clear. Tympanic membranes were shiny and pearly gray. Mouth: No lesions. Dentition was fair. Throat noninjected. Swallowing normal. Tongue midline and normal appearing. Thyroid without masses or nodules. No adenopathy and full range of motion. RESPIRATORY: Breath sounds were clear, full inspiration. No wheezes, rales, or rhonchi. CARDIAC: Regular rate and rhythm, S1 and S2. No murmurs, rubs or gallops. No carotid bruits. ABDOMEN: Soft and nontender. No masses. No renal or aortic bruits. No organomegaly. Bowel sounds were present. GENITOURINARY: Deferred. RECTAL: Deferred. BACK: No kyphoscoliosis, full range of motion. No costovertebral angle tenderness. EXTREMITIES: Full range of motion. No cyanosis, no clubbing, and no edema. SKIN: No lesions and no lymphadenopathy. NEUROLOGIC: Cranial nerve I: Sense of smell intact. Cranial nerve II: Visual acuity normal. Pupils equal, round, reactive to light, and accommodation. Fundi were benign. Cranial nerves III, IV, and VI: EOMI. Cranial nerve V: Full facial sensation bilaterally and clinches jaw. Cranial nerve VII: Smiles, closes eyelids, and raises eyebrows. Cranial nerve VIII: Hearing intact to finger rubs. Cranial nerve IX-X: Swallowing intact, lifts palate, gag reflex, and taste intact. Cranial nerve XI: Shrugs shoulders and turns head against resistance. Cranial nerve XII: Tongue protrudes midline. No atrophy or fasciculations to resting tongue. Motor sensory: Equal muscle strength in all groups tested. No atrophy or fasciculations. Intact pain and light touch, proprioception, and stereognosis. Rapid alternating movements intact. Normal gait. Heel walking and toe walking were normal. Romberg was negative.
MT Sites Search Engine - Searches only MT Websites To Get You Relevant Results: