Sample 1
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable and afebrile.
GENERAL: Well developed patient in no acute distress. The pupils are equal and
reactive. Neck is soft.
LUNGS:
Clear to auscultation.
HEART:
Regular rate and rhythm.
ABDOMEN: Soft and nontender.
PELVIC:
Will be performed during exam under anesthesia.
EXTREMITIES: No edema or cyanosis. Homans' sign negative.
NEUROLOGY: Subjective left arm and left leg weakness per patient report,
longstanding CVA. The patient walks at home without assistance.
Sample 2
PHYSICAL EXAMINATION:
VITALS:
Blood pressure 170/94. Weight 118 pounds. Temperature 98.2. Pulse
96.
Respirations 16.
GENERAL: This is a well-developed patient in no acute distress.
HEENT:
Pupils equal round and reactive.
NECK:
Soft.
LUNGS:
Clear to auscultation.
HEART:
Regular rate and rhythm.
BREASTS:
No mass, skin change or nipple discharge.
ABDOMEN: Soft with some mild lower quadrant tenderness, no rigidity or rebound.
BACK:
No costovertebral angle tenderness.
PELVIC:
No vulvar or urethral lesions. The upper vagina is distorted and I cannot
visualize a normal appearing cervix due to a mass affect in the pelvis.
There is blood in the posterior fornix. Bimanual and rectal examinations
show a large pelvic mass filling the pelvis and replacing any normal
uterus tubes or ovaries. I cannot separately palpate a uterus versus
fallopian tubes or ovaries. There is a small dimple at the bottom
suggestive of a cervix. There is no parametrial nodularity. There are no
obvious intrinsic rectal lesions. Anal sphincter tone is present.
EXTREMITIES: Thin with no pitting edema or cyanosis.
Sample 3
PHYSICAL EXAMINATION:
VITAL SIGNS:
Blood pressure 124/72, weight 116 pounds, temperature 98.2
degrees, pulse 72, and respirations 16.
GENERAL:
Chronically ill, thin appearing patient who is in some upper airway
distress, but is able to ambulate without assistance.
HEENT:
Pupils are equal.
NECK:
Soft.
LUNGS:
Clear with some decreased breath sounds at the base of both
lower lobes. There is what appears to be a thoracostomy tube in
place in the left chest attached to a large closed drain.
BREASTS:
ABDOMEN:
BACK:
PELVIC:
EXTREMITIES:
NEUROLOGIC:
Breast tissue is minimal. The right breast is free of any abdominal
mass, skin change, or nipple discharge. Left breast exam is
limited as she has surgical incision that side, but again she has no
obvious abnormality.
Lymph node survey:
No cervical,
supraclavicular, or inguinal adenopathy.
Soft, scaphoid, and flat. No liver or spleen enlargement. No mass
or fluid wave.
No CVA tenderness.
No vaginal, vulvar, or urethral lesions. Cervix is grossly normal.
The uterus is a bit enlarged and irregular suggestive of fibroid. I
cannot palpate the ovaries and there is no obvious pelvic mass.
There is no parametrial nodularity. The rectum is free of any
lesions. Anal sphincter tone is present.
Non-pitting edema in the left lower extremity, no obvious palpable
vascular cords, clear asymmetry from the other side. Homans'
sign negative. Right extremity is thin, but no edema or cyanosis.
The patient is alert and oriented to person, place, and time.