Physical Examination

A physical examination, medical examination, or clinical examination (more popularly known as a check-up) is the process by which a medical professional investigates the body of a patient for signs of disease. It generally follows the taking of the medical history - an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record. Read more at Wikipedia.



You are in the "Most Common" section of this website which deals with the most common occurrences of sentences and normal values in medical report. Read below to know more about the most common Physical Examination.


General
The patient is a ___-year-old male/female in no apparent distress.  The patient appears his/her stated age.  The patient is well developed, well nourished male/female, in no apparent distress.  The patient is alert and oriented x3.

Vital Signs
Blood pressure 120/80, pulse 60, respirations 18, pulse oximetry 99% on room air, temperature 98.6 degrees Fahrenheit (37 degrees centigrade).

HEENT
Head:  Normocephalic and atraumatic.  Face is symmetric.
Mouth:  Oral mucosa is pink and moist.  Tongue is midline.  Teeth are in good repair.
Eyes:  Pupils are equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Extraocular muscles are intact.  There is no scleral icterus.  Conjunctivae are pink.  Visual fields are normal.  Fundoscopic exam is normal.
Ears:  Tympanic membranes are pearly gray to cone of light.  Rinne and Weber tests are negative.

Neck
No bruit.  There is no jugular vein distention.  Carotid pulses are equal and symmetric.  There is no neck vein distention.  There is no lymphadenopathy.  There is no thyromegaly.

Heart
Regular rate and rhythm.  S1, S2 normal.  There are no murmurs, rubs, or gallops.  There is 1/6 systolic ejection murmur heard best at the fifth intercostal space.  Heart rate and rhythm are regular.  There is no S3 or S4.

Lungs
Clear to auscultation and percussion bilaterally.  There are no wheezes, rales, or rhonchi.  There is no pleural effusion.  There is no dullness to percussion.

Abdomen
Soft, nontender, nondistended.  Bowel sounds are present in all four quadrants.  There is no distention.  There is no rebound tenderness.  There is no McBurney's point tenderness.  Murphy's sign is negative.  There is no hepatosplenomegaly.

Extremities
There is no cyanosis, clubbing, or edema.  There is no calf tenderness.  Pedal pulses are palpable.  Deep tendon reflexes are equal and symmetric. There is brisk capillary refill.

Neurologic
The patient is alert and oriented x3.  Cranial nerves II through XII are grossly intact.  Gait and station are normal.  Mood and affect are appropriate.  The patient is able to speak in full sentences.  The patient is able to move all four extremities.
Transcription tips
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Side Headings
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Client Specifications
Guidelines set by the client or the hospital to do their work in a certain specified format is called client specification.  AAMT guidelines are the fundamental rules which every Medical Transcriptionist should know.  AAMT guidelines gives you an overall information about specifications and/or rules of transcription...
Keyboard Shortcuts
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Home Transcription
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