Deepa Rathi
Physical Examination Examples
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4, heart rate 72,
respiratory rate 16, blood pressure 132/66. GENERAL: Lying in the bed, not in acute
distress or acute pain. NEUROLOGIC: Awake, alert, oriented. No focal deficits noted.
Sensory intact. CARDIOVASCULAR: S1, S2 heard regular. No audible murmur.
RESPIRATORY: Bilateral air entry good and equal. No audible wheezing or rhonchi.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds reactive. EXTREMITIES:
No pedal edema. No calf tenderness noted. HEENT: Head atraumatic, normocephalic.
Eyes: Pupils reacting to light. Extraocular muscles intact. No icterus noted. Pallor
present. Ears: No discharge noted. No tenderness noted. Nose: No epistaxis noted.
Throat: No congestion noted. NECK: No JVD detected. No palpable lymphadenopathy.
SKIN: No cyanosis. No rash detected.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8, pulse 84 to 110,
respiratory rate 20 to 28, blood pressure 175/51. Pulse ox 94% on 6 L.
NEUROLOGICAL: Awake, alert, oriented. No focal deficiency noted.
CARDIOVASCULAR: S1, S2 heard, regular. Systolic murmur present. GENERAL:
Lying in the bed in moderate distress. Not in acute pain. RESPIRATORY: Bilateral air
entry good. Bilateral crackles present up to the midthoracic level. No audible wheezing.
ABDOMEN: Soft, obese, nontender. Bowel sounds reactive. EXTREMITIES: Pedal
edema present bilaterally. HEENT: Head atraumatic, normocephalic. Eyes: Pupils
reacting to light. Extraocular movements are intact. Ears: No discharge noted. Nose: No
epistaxis noted. Throat: No congestion noted. NECK: No JVD detected. No palpable
lymphadenopathy. SKIN: No cyanosis detected.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100 degrees, went up to
102.6, pulse 68, respiratory rate 18, blood pressure 105/65 with 94% saturation.
GENERAL: Lying in the bed, not in acute distress, in moderate pain. NEUROLOGIC:
Neurologically awake, alert and oriented, no focal deficiency noted.
CARDIOVASCULAR: S1, S2 heard, irregular systolic murmur present.
RESPIRATORY: Bilateral air entry good and equal, no audible wheezing or rhonchi.
ABDOMEN: Soft, nontender, nondistended, bowel sounds reactive. HEENT: Head
atraumatic, normocephalic. EARS: No discharge noted, no tenderness noted. EYES:
Pupils reacting to light, extraocular muscles intact, no icterus noted, pallor present.
NOSE: No epistaxis noted. THROAT: No congestion noted. NECK: No JVD detected,
no palpable lymphadenopathy. EXTREMITIES: Left lower extremity redness from ankle
to the groin area, tender to touch, warm, swollen up to the ankle to the thigh. Right lower
extremity with trace pedal edema present. SKIN: No cyanosis detected.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6, pulse 77, respiratory
rate 20 to 26, blood pressure 131/60 to 155/76, pulse ox 92% on room air and 100% on 3
L. NEUROLOGICAL: Awake, alert, oriented. No focal deficiency noted.
CARDIOVASCULAR: S1, S2 heard, regular. No audible murmur. RESPIRATORY:
Bilateral air entry good and equal. Bilateral rhonchi present. ABDOMEN: Soft,
nontender, nondistended. Bowel sounds reactive. No palpable organomegaly. No
guarding or rigidity noted. EXTREMITIES: No pedal edema. No calf tenderness noted.
GENERAL: Lying in the bed, not in acute distress, coughing a lot sometimes. HEENT:
Head atraumatic, normocephalic. Eyes: Pupils reacting to light. Extraocular muscles are
intact. No icterus noted. Ears: No discharge noted. Nose: No epistaxis noted. Throat:
No congestion noted. NECK: No JVD detected. SKIN: No cyanosis detected.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.8 in the E.R. At the
time of examination, temperature went down to 97.8. Pulse 77 to 80, respiratory rate 20,
blood pressure 114/69 to 160/87. NEUROLOGICAL: Awake, alert, oriented. No focal
deficiency noted. Sensory intact. Cranial nerves 2 through 12 intact. GENERAL: Lying
in the bed, not in acute distress. Coughing sometimes. Not in acute pain.
CARDIOVASCULAR: S1, S2 heard, regular. No audible murmur. RESPIRATORY:
Bilateral air entry good and equal. Crackles and rhonchi heard in left lower lobe.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds reactive. No palpable
masses. EXTREMITIES: Trace pedal edema noted. No calf tenderness noted. HEENT:
Head atraumatic, normocephalic. Eyes: Pupils reacting to light. Extraocular movements
are intact. No icterus noted. Ears: No discharge noted. No tenderness noted. Throat:
Congestion present. NECK: No JVD detected. No palpable lymphadenopathy. SKIN:
No cyanosis detected.