Physical Exam Section Words and Phrases For Medical Transcriptionists PHYSICAL EXAMINATION: VITAL SIGNS: On examination, the

patient had a temperature of 101.5 degrees, pu lse of 83 per minute, respirations of 18 per minute and blood pressure of 143/68 . The patient was saturating at 100% on room air. GENERAL: The patient is a very pleasant lady, no evidence of distress/discomfor t. HEENT: Examination revealed no pallor, no icterus, no lymphadenopathy. The pat ient had oral thrush. The patient had mild erythema of posterior pharynx, other wise moist mucous membranes. NECK: Supple. No JVD. No rigidity. HEART: S1 and S2 present. Systolic murmur, 2/6. LUNGS: Bilaterally clear to auscultation. CHEST: PermCath site, which is now status post PermCath removal. There was red ness and streaking. The area was bandaged secondary to removal of PermCath. ABDOMEN: The patient had bowel sounds present, nontender, nondistended, obese, soft, no CVA tenderness. NEUROLOGIC: No focal neurological deficits. EXTREMITIES: Peripheral examination revealed no pedal edema. Peripheral pulses were 2+. PHYSICAL EXAMINATION: VITAL SIGNS: At the time of presentation, the patient's vital signs were stable. The patient's temperature was 98.7, pulse 92, blood pr essure 149/88 and respirations 18. GENERAL: Upon physical examination, the pat ient was alert, awake and oriented x3 with no apparent distress. CARDIOVASCULAR : Regular. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender and nondistended. Positive bowel sounds in all four quadrants. NEUROLOGIC: The p atient was with full mentation and speech. Cranial nerves II through XII were g rossly intact. Motor function on the left lower extremity psoas was 3/5, dorsif lexion of 3/5 and plantar flexion of 3/5. The patient also complained of some s ensory deficit in the back of the left foot. PHYSICAL EXAMINATION: GENERAL: The patient is well developed, well nourished and in mild respiratory discomfort. VITAL SIGNS: Pulse 97, respirations 18, blood pressure 126/82 and oxygen satura tion was 88% on room air. HEENT: Head and neck examination was normocephalic. Nares showed mild congesti on. Conjunctivae were pink. Sclerae anicteric. CHEST: Showed bilateral diffuse inspiratory and expiratory wheezing and prolong ed expiratory phase. HEART: Regular rhythm without murmurs. ABDOMEN: Soft. Bowel sounds were positive. EXTREMITIES: Showed no edema. Pulses were good distally. PHYSICAL EXAMINATION: VITAL SIGNS: His blood pressure is 142/62, respirations 19, pulse 78, temperatu re 96.5, saturations 98%. GENERAL: Examination shows middle-aged man who is awake, alert and oriented. H e is in no distress, sitting comfortably in bed. HEENT: Atraumatic and normocephalic. Pupils are reactive bilaterally. I do no t see any jaundice. Sclerae and conjunctivae appear normal. Ears: Externally, no infection. Oral cavity: Moist mucous membranes. No deviation of the tongu e. No deviation of angle of mouth. NECK: Supple. No JVD elevation. Trachea is midline. No lymphadenopathy or th yromegaly. CHEST: Good bilateral air entry. No wheezes. No crackles.

CARDIOVASCULAR: S1 and S2 heard. No gallops. ABDOMEN: Soft, nontender. CENTRAL NERVOUS SYSTEM: Intact, no focal findings. RECTAL: Deferred. PERIPHERAL EXAMINATION: No edema, discoloration, cyanosis or clubbing.

PHYSICAL EXAMINATION: General: He is an obese white male. He is alert and ori ented x3 and in no acute distress at this time, though he cannot lift himself to sit up. HEENT: Head is normocephalic and atraumatic. Extraocular movements i ntact. Neck: There is no neck vein distention or carotid bruits auscultated. Lungs: Have decreased excursions though lungs are clear to auscultation. Heart : Has a regular rate and rhythm. S1 and S2 without murmur, rub or gallop. Abd omen: Has positive bowel sounds, nontender, nondistended without hepatomegaly. Extremities: There are pulses, 1/4, in the left leg. It feels cooler than the right. There is no edema noted and venostasis markings are noted, and the pati ent does have difficulty sitting himself up because of his body habitus though h e does move his legs and arms on command.

PHYSICAL EXAMINATION: Alert, oriented female who is anxious and in some distres s. She is afebrile with a blood pressure of 186/85, pulse of 96 and regular, re spiratory rate of 18 and unlabored. There was no jaundice. Her conjunctivae an d eyelids were normal. She has full extraocular movements. Her oral cavity and oropharynx are unremarkable. There is no evidence of adenopathy in her head, n eck or supraclavicular regions. Trachea is midline. Thyroid is not enlarged. The lungs fields are clear, symmetrical air entry. Her heart exam is normal wit hout murmurs, rubs or bruits. There are no abdominal masses. No tenderness. N o hepatosplenomegaly. She has a massively swollen left leg and poor vascular su pply to the ankle and distal tibia and fibula with atrophy and redness of the ti ssues.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.5 degrees, pulse 91, respira tions 22, and blood pressure 121/76. GENERAL: She is a young female appropriat e for her age. She was lying on the stretcher comfortably. SKIN: Showed dark macular lesions on the back. HEENT: Head was normocephalic and atraumatic. Ey es: Pupils were equally round and reactive to light and accommodation. Positiv e for dry, white crust on the eyelids bilaterally. Supraorbital swelling bilate rally. Ears: No discharge. Canals patent. Tympanic membranes were pearly whi te. Nose: Patent, no polyp, no congestion of the nasal turbinates. No dischar ge. Upper lip showed crusted white lesions with dried blood on them and obvious swelling. Lower lip was also obviously swollen with serosanguineous discharge. The patient was unable to open the mouth. NECK: Supple. No JVD. Left poste rior cervical lymphadenopathy. Lymph node of about 1 cm. CHEST: Anterior ches t wall was nontender to palpation, equal expansion bilaterally. HEART: First a nd second heart sounds were appreciated. Regular rate and rhythm. No murmur, r ales, or gallops were appreciated. LUNGS: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi were appreciated. ABDOMEN: Soft, nontender, and nondistended. Bowel sounds were positive. No organomegaly was appreciated. P ELVIC: Pelvic examination did not reveal any lesions like blisters or vesicles. No discharge. Pelvic examination, as per OB/GYN consult in the ER, did not re veal any abnormality. The cervix was thick and closed. No discharge was observ ed. MUSCULOSKELETAL: Free range of motion. No deformities. No swelling or te nderness of the joints. EXTREMITIES: No lower extremity edema. No cyanosis or clubbing. Pulses were strong and positive bilaterally both in the upper and th e lower extremities. NEUROLOGIC: She was awake, alert, and oriented to time, p

lace, and person. Cranial nerves II through XII were intact. No sensory or mot or deficits were appreciated. No lesions along any dermatomes were appreciated.

PHYSICAL EXAMINATION: She is 5 feet 5 inches, 138 pounds, in no acute distress. Her blood pressure is 144/82. Pulse is 78. She is slightly anxious but well app earing and in no acute distress. Head is normocephalic and atraumatic. Sclerae a nicteric. Pupils are equally round and reactive to light. Extraocular muscles ar e intact. Oropharynx: Clear with no edema or exudate. Tympanic membranes are pa tent bilaterally. Neck is supple. No lymphadenopathy or thyromegaly. Lungs are c lear. She has a regular heart rate and rhythm. Normal S1 and S2. Abdomen is soft , nontender, and nondistended. Breast exam shows no masses, no asymmetry, no sup raclavicular or axillary adenopathy. Extremities show no clubbing, cyanosis or e dema.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6, O2 saturation 100%, pulse 94, blood pressure 112 /74. She is 5 feet 6 inches, weighs 142 pounds. GENERAL: The patient is pleasant, in no apparent distress and looks well. SKIN: Her skin is warm and dry. HEENT: Pupils equal and react to light. Mucous membranes are moist. Ears: Wit hout erythema. Posterior pharynx without erythema or exudate. Sinuses are nonten der. NODES: She has a tiny, pea-sized left posterior node present. NECK: Supple. LUNGS: Clear without rales, rhonchi or wheezes. SPINE: Without bony tenderness or paravertebral spasm. HEART: S1, S2, regular rate and rhythm. Carotids without bruits. ABDOMEN: Positive bowel sounds, nderness. BREASTS: Medium size, st without masses or tenderness. screte lumps or masses. Axillary soft, and nontender without HSM, without CVA te round, regular. Nipples are everted. Right brea Left breast without masses or tenderness. No di and epitrochlear nodes are negative.

EXTREMITIES: Strength and sensation is intact to upper and lower extremities. D TRs absent upper extremities; 3+ knees, 2+ ankles. Good pedal pulses.

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 auscultat ion bilaterally. Her heart is regular rate and rhythm. She has no evidence of sp inal tenderness. Her abdomen is soft and nontender without evidence of hepatospl enomegaly. Her extremities are without clubbing, cyanosis, or edema. Neurologica lly, she is alert and oriented x3. Her breasts are of moderate size, pendulous,

and symmetric. She has a well-healed medial inframammary incision that is barely visible and does not cause any skin retraction. She has no evidence of nipple d ischarge, nipple retraction, or other skin changes bilaterally. I could not appr eciate any concerning dominant masses in either breast.

PHYSICAL EXAMINATION: VITAL SIGNS: On exam, the patient is afebrile. Vital signs are stable. GENERAL: He is an alert, oriented, pleasant male in no apparent respiratory dis tress. HEAD AND NECK: Exam is unremarkable. ABDOMEN: Soft, nontender, obese, nondistended. GENITOURINARY: Exam is significant for a normal uncircumcised penis without les ions. His testes are descended bilaterally without mass. RECTAL: Exam is significant for normal resting and voluntary sphincter tone. Hi s prostate is flat, firm, non-nodular, and nontender.

PHYSICAL EXAMINATION: GENERAL: The patient is awake, alert, and appears generally well. She is in no distress. VITAL SIGNS: Blood pressure 134/82, pulse 66, respirations 18, temperature 96.8 , oxygen saturation on room air 98%. HEENT: Unremarkable. CHEST: No respiratory distress. CARDIAC: Rate and rhythm are normal. EXTREMITIES: Exam of the left lower extremity reveals no obvious swelling, disc oloration or deformity. There is localized tenderness to palpation over the medi al femoral condyle area. There is no joint effusion appreciated. The patient is able to straight leg raise and is able to fully flex the knee with some discomfo rt. There is no ligamentous instability. There is no pain with range of motion o f the hip or ankle. The distal neurovascular status is intact. The patient's gai t is fairly normal. She is overweight. SKIN: Normal color and turgor without rash.

PHYSICAL EXAMINATION: The patient is a 5 feet 6 inch, 138-pound individual who stands with a level pelvis, is compensated. Paraspinal musculature is soft. No t rigger point or point tenderness over the back. CVA is nontender. When asked to forward flex, she could do so cleanly to 90 degrees, side bend 5 to 10, extend 1 0. She had pain with side bending and extension. Trendelenburg sign is negative. Heel-toe gait is preserved. Her lower extremity motor is 5/5, foot dorsiflexion , plantarflexion, inversion, eversion, knee extension, knee flexion, hip flexion , hip abduction. Sharp-dull sensation was intact across both feet. Reflexes in k

nees and ankles were 1+ symmetric, side to side. She had hamstring tightness on the left at about 70 degrees and on the right at about 80 to 90. Hip and knee ra nge of motion was full. Figure four maneuver was benign. Knee range of motion wa s good.

PHYSICAL EXAMINATION: VITAL SIGNS: Height 5 feet 6 inches. Weight 366. Blood pressure 162/68, heart rate 84, and respirations 16. GENERAL APPEARANCE: Morb idly obese male with a lazy eye, wearing glasses, in no acute distress, walks wi thout assistance and follows verbal commands with perfect responses. HEENT: No rmocephalic and atraumatic. Extraocular movements are intact without nystagmus. A slight left lazy eye. Pupils are equally round and reactive to light and ac commodation. No conjunctival erythema. Anicteric sclerae. Mouth: Moist and p ink. No lesions. Small oropharynx. Positive rise of uvula on phonation. NECK : No carotid bruits. No cervical or supraclavicular adenopathy noted. No JVD. No thyromegaly. HEART: Regular rate and rhythm. No murmurs, rubs, or gallop s. S1and S2 of appropriate intensity. LUNGS: Clear to auscultation bilaterall y. ABDOMEN: Morbidly obese distended abdomen, very central. Status post umbil ical hernia repair. Otherwise, no other surgical markings noted. Positive hepat omegaly. Negative rebound tenderness. Positive tympany in all 4 quadrants. EX TREMITIES: 5/5, active and passive range of motion in all extremities bilateral ly. Deep tendon reflexes are 2/4 bilaterally. Vascular: Edematous, erythemato us legs bilaterally from the knees down. There is an ulcer on the upper tibia, on the right leg; +3 pitting edema, hot to touch. DP and PT pulses are 1/4 bila terally. NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII int act. Proprioception intact. Sensory examination is intact.

PHYSICAL EXAMINATION: General: The patient is conscious, alert, and oriented. He is well built but he is malnourished with loss of muscle mass. He was not i n any acute distress when I saw him. Vital signs: Temperature 99.3 degrees Fah renheit. Heart rate is 131. Sinus tachycardia with occasional PACs and blood p ressure has now improved from 91 to 118 systolic. Diastolic blood pressure is i n the 70s. HEENT: Normocephalic. No jaundice. Pupils are equal and reacting to light. Neck: No jugular venous distention or lymphadenopathy. No thyromega ly. Cardiovascular system: Heart sounds are regular. S2 is single. He has fl ow-type systolic murmur, grade 2/6. No pericardial rub. Respiratory system: A ir entry is slightly diminished over the right base, otherwise lungs are clear. Abdomen: Soft and nontender. No organomegaly or masses. Bowel sounds are sli ghtly hypoactive. Extremities: No peripheral edema. No calf tenderness. Peda l pulses are not well palpable. No petechia or any vasculitic lesions.

PHYSICAL EXAMINATION: Examination shows an elderly female who is unresponsive t o any verbal stimuli. HEENT: She has atraumatic head. Pupils are equal and sl uggishly reactive bilaterally to light. Ears, externally, no infection. Oral c avity shows swollen lower lip with a cut on the lower lip, probably from biting. I am not sure how it may have happened. NECK: She has some left-sided gaze p reference with some resistance to movement of the neck towards the right side. Her neck is supple anteroposteriorly. No carotid bruits could be heard. No thy romegaly. CHEST: Good bilateral air entry. No wheezes. No crackles. CARDIOV ASCULAR SYSTEM: Irregularly irregular rhythm. ABDOMEN: Soft, nontender. CENT RAL NERVOUS SYSTEM: Could not be fully evaluated, but the patient does have fla ccidity on the right upper and lower extremity. Left side, she has some strengt h. She resists to any passive movements on the left side. However, she is not following any verbal commands, but she does respond to tactile and painful stimu li. Babinski sign is equivocal bilaterally. RECTAL: Deferred. PERIPHERAL EXA

MINATION: No edema, discoloration, cyanosis or clubbing.

PHYSICAL EXAMINATION: On exam at this time, blood pressure 142/52 in the right arm sitting, heart rate 72 per minute and minimally irregular and respiratory ra te 18-20 per minute. Temperature was 101.2 last evening and is 98.4 at this tim e, weight is 286 pounds. Funduscopic exam is deferred. He has no true exanthem or xanthelasma. Jugular venous pressure is normal with no hepatojugular reflex grossly noted. No right-sided diastolic bruit is noted. No left carotid bruit s are noted. There is no gross thyromegaly. Chest is clear anteriorly with sca ttered posterior rales in the bases bilaterally. No wheezes are present. Cardi ac exam reveals normal S1, A2/P2 with no rubs, clicks, gallops, murmurs noted. Apical beat nonpalpable. Peripheral pulses are 4/4 (normal) at the radial, brac hial, carotid and femoral bilaterally. Extremities show no cyanosis or edema.

PHYSICAL EXAMINATION: Currently, resting comfortably in bed. Afebrile. Vital signs are stable. HEENT: Normocephalic and atraumatic. Neck: Supple without adenopathy. Heart: Regular rate and rhythm. Abdomen: Soft, benign, and nonte nder. Genitourinary: Both testicles are descended. The right testicle was swo llen compared to the left, is slightly tender as is the right epididymis. The i nguinal canal is normal. I do not detect any hernias. Phallus is normal withou t lesions. Neurologic: No focal deficits.

PHYSICAL EXAMINATION: The patient is lethargic. He awakens to verbal stimulati on. Neck is supple with no meningismus. Heart is regular in rhythm. Neurologi cally, speech is fluent. The patient answers questions. He appears oriented fo r the most part. He is cooperative and follows commands well. Pupils are isoco ric and sluggishly reactive. Extraocular movements are conjugate. Visual field s are full to threat. Facial movements are symmetric. Tongue protrudes in the midline. Motor exam is symmetric in the four limbs at 5/5. Sensory exam is sym metric for pain perception throughout. There is no upper extremity dysmetria. Gait and stance could not be tested. Deep tendon reflexes are 1 to 2+ at the bi ceps and brachioradialis, 1+ at the patella, and 1+ at the ankles. Toes are mut e bilaterally.

PHYSICAL EXAMINATION: On examination, the patient is alert. Neck is supple wit h no meningismus. Heart: Regular in rate and rhythm. Neurological: Speech is for the most part fluent. The patient is oriented to the place, unable to stat e the year or the month, unable to give his correct age. He does identify the c urrent president. He is cooperative and does followup commands. His pupils are isocoric and reactive. Extraocular movements are conjugate. Visual fields are full to confrontation. Facial movements are symmetric. Tongue protrudes in th e midline. Motor examination is symmetric in the four limbs at 4+/5. There is n o upper extremity pronator drift. Sensory examination is symmetric for light to uch and pinprick throughout. There is no upper extremity dysmetria and no gross gait ataxia. Deep tendon reflexes are hypoactive throughout, toes are mute bil aterally.

PHYSICAL EXAMINATION: Vital signs: Stable. She is afebrile. General: She is alert and oriented x3. Cranial nerves II: Visual fields are full to confronta tion. Cranial nerves III, IV, and VI: Extraocular movements are intact. Crani

al nerves V: Facial sensation is intact to light touch. Cranial nerves VII: N o facial droop seen. Cranial nerve VIII: Auditory acuity, bilaterally symmetri c finger rub. Cranial nerve IX and X: Good strong cough. Cranial nerve XII: Shoulder shrug bilaterally is symmetric. Cranial nerve XII: Tongue protrudes in the midline. Strength is 5/5 except 5-/5 in the left upper extremity. Sens ation is intact to light touch. Reflexes are 2 throughout. There is no Babinsk i. No evidence of meningismus. There is some photophobia symptomatically.

PHYSICAL EXAMINATION: WT: He has gained some weight, he is up to 306. P: 92. BP: 125/73. RR: 22. Saturations on room air 92%. HEENT: He has no lesion s or exudates. He has a stage III oropharynx. Neck is supple without adenopath y. Lungs: He has mildly decreased breath sounds but clear. Cardiac: Regular. Abdomen: Obese. Extremities: Trace edema.

PHYSICAL EXAMINATION: Vital signs stable. The patient is afebrile. She is ale rt and oriented to time, person, and place. Good concentration and preserved ab stract thinking. There is no evidence of dementia except mild short-term memory difficulties. Her blood pressure was 126/82. She has atrial fibrillation. He art rate is 127. Tachycardia with rapid ventricular response. She follows verb al commands. Moves all 4 extremities. No numbness. Sensory exam is normal. R eflexes are symmetric. Toes are downgoing. Gait and station are well functioni ng. Cranial nerves are intact. There was no carotid bruit. The patient has bi lateral facial spasm and blepharospasm noticed during the exam.

PHYSICAL EXAMINATION: General: Young male, lying in bed, appears thin. Alert, awake, and oriented x3. Vital Signs: Most recent vital signs, blood pressure 99/76, pulse of 75, and respirations 19. The patient is afebrile. Head and Nec k: Extraocular muscles are intact. Pupils are round and reactive. No icterus. The patient has mild pallor. No oral lesions. No throat congestion. Ears cl ear. Neck: Supple. No jugular venous distention. Lungs: Good bilateral air entry. Clear to auscultation. No crackles or rhonchi are appreciated. Heart: S1, S2 audible. Regular rhythm. No audible murmur. Abdomen: Soft, bulky, no ntender. Positive bowel sounds. No hepatosplenomegaly appreciated. Extremitie s: Right hip incision appears to be clean. No evidence of pedal edema. Homans sign is negative bilaterally. Neurologic: He is grossly nonfocal.

PHYSICAL EXAMINATION: General: Elderly male who has some cushingoid features a nd had ecchymotic skin, lying in bed, intubated and sedated. Vital Signs: Most recent vital signs, blood pressure 119/68; pulse of 101; respirations, the pati ent is breathing via the ventilator. The patient is afebrile. Telemetry is sho wing sinus rhythm, sinus tachycardia. O2 saturation 96%. Head and Neck: Normo cephalic and atraumatic. Pupils are round and reactive. The patient has ET tub e in place. Neck: Supple. No jugular venous distention. Lungs: Bilateral ai r entry. The patient has no expiratory rhonchi. No crackles. Heart: S1, S2 a udible. Regular rhythm. No audible murmur. Abdomen: Soft, bulky, nontender. Positive bowel sounds. Extremities: The patient has thin, fragile skin involv ing bilateral upper and lower extremities with multiple areas of ecchymosis. Do es not exhibit any significant edema of lower extremities. Peripheral pulses ar e weak but palpable. Neurologic: He is intubated and sedated; however, he with draws in response to tactile and painful stimuli.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.6 degrees, pulse 92, resp iratory rate 19 and blood pressure 146/84. GENERAL: He is on 1 liter nasal can nula. He is in no acute distress. Neck severely flexed to the left. Soft voic e with slurred speech and is very difficult to understand. LUNGS: Show decreas ed breath sounds in the left lower lung fields. CARDIOVASCULAR: Regular rate a nd rhythm without murmurs, rubs or gallops. ABDOMEN: Soft, nontender and nondi stended with positive bowel sounds. EXTREMITIES: Show venous stasis dermatitis and hyperpigmentation. No edema. He has bilateral finger flexion contractions with ulnar deviation at the wrist, and as mentioned above, his C-spine, his hea d is flexed to his left shoulder. He can actively reduce approximately half of his flexion. NEUROLOGIC: Unable to obtain a mental status exam, although he ap pears to be comprehending our questions and nodding appropriately. His cranial nerves are grossly intact. Pupils are equal, round and reactive to light. His strength is 4+ to 5 throughout. Sensation: He reports good light touch sensati on throughout, although testing is limited. His muscle stretch reflexes are 2+ in the right upper extremity, 1 in the left upper extremity, 3+ at the right kne e, 0 at the left knee, 2+ at the right ankle, 0 at the left ankle with downgoing toes bilaterally. No Hoffmann. No palmomental. No grasp reflex. PHYSICAL EXAMINATION: VITAL SIGNS: Vitals are pending. GENERAL: The patient is a (XX)-year-old male, pleasant, alert and cooperative, follows all commands a ppropriately, sitting in a wheelchair, speaking with mild dysarthria, in no dist ress. HEENT: Extraocular muscles are intact. HEART: Regular rate and rhythm with a 2/6 systolic murmur. LUNGS: Clear to auscultation bilaterally. EXTREMI TIES: Right hand and right ankle and lower leg edema. NEUROLOGICAL: Cranial ne rves III through XII are grossly intact, except for cranial nerve XI. Right sho ulder shrug is impaired. Cranial nerve XII, tongue deviates to right. There is also a right facial droop. Strength: Left upper and lower extremity 5/5. Rig ht upper extremity: Elbow flexion 2-/5 with no other voluntary movement in the upper extremity. Hand is flaccid. Right lower extremity: Hip flexion 3-/5 and knee extension 3+/5. Right ankle dorsiflexion 1/5. Sensation intact to light touch and to 10 g monofilament bilaterally. Stereognosis intact on the left, un able to test on the right secondary to flaccidity. Graphesthesia intact on the left and mildly impaired on the right. It took the patient several repetitions in order to name the appropriate number drawn in the palm of his hand. Cerebell ar finger-to-nose-to-finger is intact on the left. Rapid alternating movements with index finger tapping to thumb were intact on the left. No ataxia. The pat ient was unable to perform with the right upper extremity. Mental status: The patient had difficulty counting coins in the hand when a quarter, dime, and penn y were placed in view. PHYSICAL EXAMINATION: The patient was seen sitting up in a chair with both wris ts restrained on the wheelchair, well-healed craniotomy scar with tracheostomy i n place, with significant secretions with moist air mask over the tracheostomy. The patient uttered unintelligible words. With his tracheostomy plugged, he st ill was unintelligible. He was intermittently fluent but really no language exa mination could be done because of his significant confusion. His mental status examination was severe confusion with lethargy, alternating with some short-live d motor restlessness in which he picked the tubes or would pull and hold on to h is tracheostomy mask line. He never really pulled his tracheostomy tube or any of his IVs. He has not pulled his PEG or his Foley catheter. His cranial nerve examination is remarkable for poorly visualized fundi. The patient was moving and restless, and at other times, too lethargic to cooperate. Blinks to threat, both eyes. Pupils are equal and reactive. I did not see any evidence of third nerve palsy, and the patient has no asymmetry of his face that I could judge. He was uncooperative with oral evaluation of the pharynx. Tongue appeared midli ne in the mouth. No carotid bruits but auscultation obscured by tracheostomy so

unds, tracheostomy in place. Motor examination shows the patient to be equally resistant to any sort of passive movement in both arms, in a gegenhalten or para tonic rigidity style. There was some decreased withdrawal to pain on the right side suggestive of a mild underlying right hemiparesis. Reflexes were absent in the ankles, 1 at the knees, 1 in the arms, and he has a positive palmomental. Toes are nonreactive. Limb ataxia could not be judged and gait was not attempte d. ---------------------------------------------------------------------------------------------------------PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.5 degrees, pulse 86, respira tions 18 and blood pressure 154/82. GENERAL: The patient is a (XX)-year-old wh ite female, pleasant, alert and cooperative, lying semi-reclined in bed, in no a cute distress. She does have pressured speech, and there is a mild left facial droop. HEENT: Extraocular muscles are intact. No nystagmus. Moist mucous mem branes. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilater ally without murmurs. ABDOMEN: Positive bowel sounds, soft, nontender and nond istended. EXTREMITIES: No peripheral edema. NEUROLOGIC: Strength: Right upp er and lower extremity, 5/5. Left shoulder abduction, 3+/5; left elbow flexion, 4/5; and left grip, 4/5. Left knee extension, 4+/5; left ankle dorsiflexion, 4 +/5; and left toe extension, 4+/5. Sensation intact to light touch, bilateral, upper and lower extremities. Deep tendon reflexes; 3+/4 bilateral biceps, brach ioradialis and patellar. Babinski is present on the left. Mental status: The patient is oriented x3. She speaks with a pressured-type speech. There is a no dysarthria. Cranial nerves II through XII are grossly intact, except for decre ased strength in left cranial nerve XI, decreased shoulder shrug. PHYSICAL EXAMINATION: GENERAL: The patient is a well-nourished, well-developed female, in no apparent distress. VITAL SIGNS: Temperature 97.5 degrees, blood pressure 129/67, pulse 83 and respiratory rate 18. SKIN: Warm and dry with go od color and turgor. There were a few ecchymotic areas present consistent with phlebotomy site. She does have a G-tube in place. No rash is present at the pr esent time. No skin breakdown. HEENT: She does have mild right facial droop. She is otherwise normocephalic and atraumatic. PERRLA. EOMI. There is no gro ss afferent pupillary defect or conjugate gaze. TMs were clear. Oral mucosa wa s moist and pink. She is edentulous. NECK: Soft and supple without lymphadeno pathy, JVD or bruit. HEART: Regular rate and rhythm without murmurs, rubs or g allops. LUNGS: Clear to the bases bilaterally. No rhonchi, rales or wheezes. ABDOMEN: Obese but soft, nontender and nondistended. Bowel sounds were active . No rebound, guarding, pulsating masses or bruits. No CVA or suprapubic tende rness. BACK: Back, spine and paraspinal areas were unremarkable with equal wal l motion and symmetrical musculature. GENITOURINARY: Normal-appearing female. She has a mild erythematous area with breakdown, sacral or right buttock area. Tegasorb dressing is in place, approximately 1-2 cm in diameter. EXTREMITIES: There is no clubbing or cyanosis. Trace of edema bilaterally, 2+ dorsalis pedi s, posterior tibial and radial pulses. Reflexes: The patient is hyperreflexive on the left side, appears to be normoreflexive on the right. Toes were downgoi ng on the right, up in the left. Negative Babinski. Unable to perform heel-toshin secondary to left side neglect. Finger-to-nose also likewise. OBJECTIVE: Temperature 98.4 degrees, pulse 80, respirations 30 with a recheck o f 22, and blood pressure 112/82. The head and neck examination was unremarkable , except for some male pattern baldness, and the patient is receiving 2 liters o f oxygen via nasal cannula. There is no pursed lips breathing. There is no acc essory muscle use for respiration. The lungs were clear to auscultation, except for some decreased breath sounds in the bases. The heart had a regular rate an d rhythm without murmur. The abdomen was soft, nontender, with active bowel sou nds. A paradoxical pattern of breathing was noted. Thigh-high Ace wraps and TE

D hose were worn. A thigh strap was in place to aid with leg positioning. Ther e is a PICC line in the left arm. Trace lower extremity edema was noted.

OBJECTIVE: Temperature 97.4 degrees, pulse 91, respirations 17, and blood press ure 127/81. The head and neck examination showed a healing scar on the left lip . She was wearing a TLSO with Minerva extension. The brace was fitting well. Heart and lung examinations were within normal limits. The abdomen was soft, no ntender, with active bowel sounds. There was no lower extremity edema. Modifie d Ashworth score was 2-3.

PHYSICAL EXAMINATION: Temperature 97.2 degrees, respirations 19, pulse 93, and blood pressure 132/64. He is alert, he is oriented, but sustained attention is quite poor. Simple attention is intact. He is concrete in his abstractions. S hort-term recall is very poor for information about his hospitalization. Prior levels of function are declined, even his prior graduation history from college. His language is a little bit dysarthric. Insight into his condition is modera tely impaired. He is concrete on abstractions and similarities. Cranial nerves : He has a history apparently of alternating exotropia. It looks like that is what it is rather than internuclear ophthalmoplegia, but he does have a left APD . Disk is pale on the outside. The pupils are reactive and the left pupil is s lightly larger than the right. He has flattening of the right face but intact s ensation, spastic gag, and intact sensation in the palate and midline tongue. C arotid examination is unremarkable. Cardiac examination reveals regular rate an d rhythm. No murmur. Motor: The patient has good strength in his upper extrem ities, bilateral thigh. Reflexes are 1 in the arms. In the legs, he has clonus at the ankles, but I could not get reflexes. Lower extremity strength is 3- in the left iliopsoas, 2 on the right, 3- in the quads bilaterally, 2 in the hamst rings and 2 to 3- in the dorsiflexors. He has decreased proprioception in both hands and both feet. Vibration is diminished to the knees. He has moderate ata xia on finger-to-nose. Legs are not tested due to weakness. Gait was not attem pted but he has moderate impairment in trunk control, though he does have some t runk control and sits reasonably well on the scooter chair. He has significant truncal ataxia. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 143/82, pulse 86, respiratio ns 21 and unlabored. GENERAL: She is a large, well-nourished, white female, in no acute distress. Has numerous superficial lacerations and abrasions. SKIN: Has fair color and turgor. Difficult to ascertain much secondary to numerous d ressings, including wound VAC. HEENT: She appears grossly atraumatic. There i s no gross asymmetry. She has numerous avulsed teeth. She appears to have no m alocclusion. The mandible is nontender. She had normal midline structures. PE RRLA. EOMI. No APD. There is conjugate gaze. She does not have raccoon eyes. Cannot appreciate any gross step-off. TMs were clear bilaterally. No gross b leed. Nose is nontender on evaluation presently. NECK: Soft and supple withou t JVD or bruit. She does have mild submandibular lymphadenopathy present. It i s nontender however. It is bilateral and symmetrical. She has fair range of mo tion. She does have a soft collar brace on at this point of time. It is more f or comfort of the patient at this point in time. BACK: Back and spine and para spine were unremarkable with equal chest wall motion. HEART: Regular rate and rhythm with 1/6 systolic ejection murmur. CHEST: Had slightly diminished breat h sounds bilaterally at the bases. No gross rhonchi, rales or wheezes. Normal PMI. ABDOMEN: She has a large abdominal wound with wound VAC in place. Black sponge dressing in place. It is set to 125 mmHg. No present drainage at this t ime. She has bilateral casts on upper extremities as well as one on lower extre mities, short leg walking cast. There appears to be some yellowish drainage pre

sent as well as some slough material about the periphery of the abdominal wound itself and has appropriate tenderness and mild erythema about the edges present, 1-2 cm; however, there is no gross induration appreciated. She has numerous ca sts, superficial lacerations, abrasions and contusions. Hemovac to the left hip area for revision of left hip ORIF, that was discontinued prior to discharge. GENITOURINARY: Normal-appearing female. EXTREMITIES: As stated above. Propri oception is preserved; however, difficult to ascertain secondary to pain in the left lower extremity. Capillary refill and nail beds appear to be pink and appr opriate. Motor is intact in all extremities. NEUROLOGIC: Neurologically, I ca nnot appreciate any gross deficits at this time. However, this is difficult sec ondary to numerous casts and obstructions on evaluation. She appears to have a small, possibly, pressure sore on the left heel, slightly violaceous in color. There is no skin breakdown. It is no fluctuant. It is not soft or mushy. Cann ot appreciate gross heel-to-toe at this point in time secondary to casting. The patient is not able to ambulate around at this point in time, as she likely is nonweightbearing on the left lower extremity. Cranial nerves do, however, appea r preserved bilaterally. PHYSICAL EXAMINATION: Temperature 98.5 degrees, pulse 101, respirations 18, blo od pressure 141/78 and oxygen saturation 97%. Eyes are open with a left gaze de viation, right hemiplegia, which is flaccid, right decreased blink to threat. I could not examine her oropharynx, as she was unable to open it. Pupils were eq ual and reactive, and fundi were poorly visualized. Reflexes were absent throug hout. She does move the left arm spontaneously but not the left leg. She withd raws the left leg to pain, and she grimaces to pain for all four extremities. S he has foot drop bilaterally, worse on the right, and her toes are unreactive. PHYSICAL EXAMINATION: General: The patient was comfortable at the time of exam ination and no shortness of breath. Vital Signs: Blood pressure 126/77, pulse 88, afebrile, with respiratory rate of 18 per minute. Head and neck examination : Pink conjunctivae, anicteric sclerae. Normal eye movements. Mouth, no lesio ns. Neck: Supple. No jugular venous distention, tenderness, thyromegaly, lymp hadenopathy or masses. Chest: Bilateral equal expansion, resonant to percussio n, with clear air entry bilaterally. Heart: Normal S1 and S2. No S3. No murm urs or gallops. Abdomen: Benign, nontender and nondistended. No masses, organ omegaly or ascites. Limbs: No finger clubbing or pedal edema. Neurologic exam ination: The patient is alert and oriented x3. No signs of focal motor, sensor y or neurological deficits. Skin: Normal. Lymph nodes: None detected. PHYSICAL EXAMINATION: Shows a well-developed, well-nourished white female, cons cious, alert, oriented, in slight distress due to pain in the left hip. The pat ient is afebrile. Vital signs are stable. HEENT: Normocephalic. Eyes: Pupil s equal, round, reactive to light and accommodation. Extraocular movements are full and equal. Neck shows no palpable tenderness or spasm. No lymphadenopathy or thyromegaly. Fair range of motion. At the present time, the patient is lyi ng supine with pillow between her legs, and on removal of the pillow, the patien t still has a flexion contracture in the left hip. There is a large ecchymosis, approximately 9 x 10 cm over the left greater trochanter area, and clinically, there are no fluctuations suggesting hematoma. Diffuse tenderness in the groin and over the lateral hip area. Range of motion of the left hip is reduced in al l planes with spasm around the hip. There is no rotational deformity of the lef t lower extremity but possibly minimal shortening compared to the right lower ex tremity. CNS: Sensation intact in all dermatomes. Deep tendon reflexes 1+ and equal. Plantar reflexes bilaterally. Pedal pulses are faint but present both sides. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.5 degrees, pulse 72, resp irations 19, and blood pressure 142/64. HEENT: Head is atraumatic, normocephal

ic and without bony deformities. Ears are unremarkable for bulging, retraction of TMs, erythema, drainage or PE tubes. Eyes: Pupils are equal, round and reac tive to light and accommodation. EOMS intact. No evidence of ptosis or conjunc tivitis. Nose: Nasal mucosa is pink and dry without evidence of erythema, drai nage, or lesions. Throat: The patient s oral cavity is unremarkable for exudate, erythema or oral candidiasis. NECK: Supple without JVD, goiter or lymphadenop athy. LUNGS: Clear to auscultation. No rhonchi, wheezing or rales heard. HEA RT: Tachycardic with a heart rate of 103. No murmurs, rubs or gallops heard. ABDOMEN: Soft, obese and nontender. Bowel sounds are present in all four quadr ants. EXTREMITIES: The patient s right knee incision site is clean, dry and inta ct. There is mild erythema, warmth and edema present around the right knee. Th e wound appears dehisced and shows no evidence of purulent drainage or odor. No calf tenderness on exam. The patient does have palpable DP pulses bilaterally. NEUROLOGICAL: The patient is alert and oriented to person, place and time. C ranial nerves II through XII appear intact. No evidence of sensory loss. Upper extremity motor strength is 5/5. Left lower extremity motor strength 5/5. Rig ht hip flexion 0/5. Right knee flexion 3/6. Right EHL 5/5. SKIN: Unremarkabl e for pressure wounds. PHYSICAL EXAMINATION: Shows a well-developed, well-nourished white female, cons cious, alert, oriented, in no acute distress. The patient is afebrile. Vital s igns are stable. HEENT: Normocephalic. Eyes: Pupils equal, round, reactive t o light and accommodation. Extraocular movements are full and equal. Neck show s no tenderness or spasm. No lymphadenopathy or thyromegaly. Extension is slig htly limited with no pain. There is a left below-knee amputation stump. Tip is conical with no tenderness, good range of motion of the knee. Right lower extr emity is noted to be slightly swollen and indurated and with slight erythema. T he skin is dry and scaly. There is a 2.6 x 2.2 cm ulcer of the lateral aspect o f the right heel with very minimal slough in the base. No active drainage is se en. Slight erythema around the ulcer edges, which does not appear to extend too deeply. Minimal tenderness around the ulcer margins. Pedal pulses not palpabl e. Toenails are noted to be thickened and brittle with possible fungal infectio n. Sensation is reduced in the foot. Fair range of motion of the ankle and toe s. PHYSICAL EXAMINATION: General: The patient is an elderly gentleman appearing h is stated age and who is hemodynamically stable. HEENT: Normocephalic and atra umatic. Pupils equal, round and reactive to light and accommodation. Extraocul ar movements intact. Mouth is without lesions. Neck: Supple without thyromega ly. No jugular venous distention or bruits noted. No lymphadenopathy noted. C hest: Clear to percussion and auscultation. Cor: S1 and S2. No S3 or S4 note d. Positive 2/6 murmur heard over the precordium. Abdomen: Scaphoid, soft and benign. Bowel sounds are normoactive. There is no hepatosplenomegaly noted. Extremities: Reveal bilateral 3+ pitting edema with erysipelas extending threefourths on the left and two-thirds on the right. Neurologic: The patient is al ert and oriented x3. Cranial nerves II through XII are intact. Motor and senso ry systems are normal. PHYSICAL EXAMINATION: General: The patient is a well-developed, well-nourished white male who appears to be in no acute distress. Vital Signs: Blood pressur e is 152/74 and weight is 178. HEENT: Within normal limits. There is no scler al icterus. Lungs: Clear to A and P. Heart: Soft, 1 to 2/6 systolic murmur. There is no gallop or rub. Abdomen: Scars from previous surgery. There is no organomegaly or masses. Bowel sounds are present. There is no tenderness. Re ctal: Heme-negative stool. There are no masses. Extremities: No clubbing, cy anosis or edema. Neurologic: Grossly intact.

PHYSICAL EXAMINATION: General: The patient is an averagely built, elderly whit e male, who is not in acute distress. Vital Signs: Stable, as noted on the cha rt. HEENT: Examination unremarkable. Neck: Supple. No carotid bruits. Hear t: S1 and S2 are normal. No murmur, gallop or rub. Lungs: Clear. Neurologic : He is alert. He knows he is in the hospital. He has no recollection of even ts from yesterday, clearly. He follows commands appropriately. His speech is d ysarthric, which is unchanged from his previous exams. Pupils are 3 mm, round, reactive to light and accommodation. No visual field defects. Extraocular move ments are full and no nystagmus. Mild left facial weakness, of central type, is still seen, residual from previous stroke. Other cranial nerves intact. He ap pears to be swallowing fairly well. Motor examination reveals spastic left hemi paresis. Strength is 0/5 in the left upper extremity and 3 to 4/5 left lower ex tremity, which is unchanged from previous one, 5/5 on the right side. Generaliz ed hyporeflexia. Plantar response is downgoing on the right, upgoing on the lef t. PHYSICAL EXAMINATION: General: The patient is an overweight, middle-aged white female not in acute distress. Vital Signs: Stable as noted on the chart. HEE NT: Examination unremarkable. Neck: Supple. No signs of meningeal irritation . No carotid bruit. Heart: S1 and S2 normal. No murmur, gallop or rub. Lung s: Clear. Neurologic: She is alert and oriented in all three spheres, general ly pleasant and cooperative. No dysarthria or aphasia. Memory grossly intact. Pupils are 4 mm, round and reactive to light and accommodation. No visual fiel d defects. Extraocular movements are full. No nystagmus. No facial asymmetry. Auditory canals are intact. Muscle bulk and tone are within normal limits. N o evidence of any focal, motor or sensory deficits. She does have some limitati on of the right knee movement because of pain. Intact deep tendon reflexes, whi ch appeared to be hypoactive. Plantar response is downgoing bilaterally. Finge r-to-nose test did not show any ataxia. PHYSICAL EXAMINATION: Vital Signs: Blood pressure 133/85, heart rate 80, respi ratory rate 19 and temperature 97.5 degrees. Weight 208 pounds. Height approxi mately 5 feet 7 inches. HEENT: Head is normocephalic. Conjunctivae are pink. Oropharynx is clear. Neck: Supple. There are no masses. There is no tendern ess. Chest: Without any deformities. Abdomen: Soft and nontender without org anomegaly. Extremities: Did not show any cyanosis or clubbing. Neurologic: M ental status, he is alert and he is cooperative. Speech is dysarthric. He has difficulty with his saliva and was coughing because of this. Tongue is midline. He has good shoulder shrugs. Motor examination showed he had 5/5 strength in the upper and lower extremities. No gross ataxia was noted on finger-to-nose te sting. Gait is not tested. There was no facial numbness. PHYSICAL EXAMINATION: Temperature 98.2, pulse 82, blood pressure 118/70 and T-m ax 100. In general, the patient is awake and alert. He is sitting in a chair. He is able to answer some questions but does appear to have some trouble with memo ry. HEENT: Pupils are reactive bilaterally. Sclerae anicteric. Conjunctivae non injected. Oral mucosa moist. No thrush or pharyngitis. Neck: Supple. Trachea mi dline. No palpable thyromegaly. Lymph: No frank cervical, supraclavicular or epi trochlear adenopathy. Chest: Symmetrical excursion. Lungs are clear to ausculta tion without wheezes. The port site is in the right pectoral area and does not a ppear to have any redness or tenderness. Cardiac: Regular rate and rhythm witho ut rub. Abdomen: Nondistended. Normoactive bowel sounds. No guarding or rebound tenderness. Ileal conduit is present in the right lower quadrant. The ostomy sit e appears to be pink. Urine appears fairly clear with only a small amount of sed iment noted. Back: No CVA tenderness. Extremities: No clubbing or cyanosis. No palpable cords. No calf tenderness to palpation. The patient appears to have go od peripheral muscle tone to palpation. The skin is without diffuse rash. No ves icles or bullae. No Janeway lesions or Osler nodes. Peripheral IV site has no ce

llulitis or phlebitis. PHYSICAL EXAMINATION: The patient denies mental status examination. The patien t is an average built, casually groomed male with swollen left eye and in no acu te distress. He was pleasant and cooperative and maintaining good eye contact. There was no evidence of any psychomotor dysfunction. His affect was euthymic and he described his mood as "good." His speech was clear, coherent and goal di rected and there was no evidence of any formal thought disorder. The patient re ported vague paranoid ideation during the time of cocaine intoxification, but cu rrently denies any overt psychotic symptoms or any previous history of psychosis or other significant difficulties besides violent behavior and antisocial behav ior. Cognition: The patient was alert and oriented to person, place and time. His recent and remote memories were fair. His attention and concentration were fair. His fund of knowledge appears to be below average and his insight and ju dgment were poor. PHYSICAL EXAMINATION: This is an elderly male, confused and disoriented, but in no apparent distress. Blood pressure is 110/53, heart rate of 113, respiratory rate of 24 and saturation with 2 L nasal cannula is 100%. HEENT: Unremarkable . Neck: Jugular venous pressure is within normal limits. Carotid upstrokes ar e normal. No carotid bruits. Lungs: Clear to auscultation. Heart: PMI nondi splaced. The first and second heart sounds are normal in intensity. There is a 1/6 systolic murmur, heard best below the apex. Abdomen: Soft and nontender w ith active bowel sounds. No organomegaly. No abdominal bruits. Extremities: No clubbing or cyanosis. There is trace edema in the feet. Neurologic: Gross ly nonfocal. Peripheral pulses are 2+/2, equal bilaterally. PHYSICAL EXAMINATION: The patient is a (XX)-year-old woman who is alert and ori ented x3, comfortable at rest. Her vital data includes a temperature of 98.5, h eart rate 72, blood pressure 142/82 and respirations 21. Head and neck examinat ion shows pupils equal, round, reacting to light and accommodation. Extraocular muscles are intact. ENT examination is normal. There is no JVD. There is no lymphadenopathy. No thyromegaly. Neck is supple. Chest examination shows firs t and second heart sounds, normally heard. No third sound, no fourth sound, and no murmurs. Auscultation of the lungs shows bilateral vesicular breath sounds . Examination of the abdomen shows a soft and scaphoid abdomen. There is a lon gitudinal scar in the midline, which is a healthy scar. There is a deep tendern ess in the epigastrium in the left upper quadrant of the abdomen. There is no r ebound tenderness. No hepatosplenomegaly. No ascites. Normal peristaltic soun ds are heard. Extremity examination shows no edema. No rash. No focal neurolo gical deficit. PHYSICAL EXAMINATION: Reveals alert and cooperative gentleman whose weight is 1 60 pounds, temperature 99.5, pulse 92, respirations 18, blood pressure 131/74 an d O2 saturation is 96% on room air. HEENT: Shows him to be normocephalic. Th ere is no gross scleral icterus, conjunctival petechiae or pallor. Mouth and Th roat: Clear. Neck: Supple and nontender. No palpable mass or adenopathy. He has a well-healed thyroidectomy incision. Chest: Shows some percussion and au scultation and did not show any focal wheezes or rales. On the defibrillator si de, left upper chest has some hemorrhagic brawny changes. It does not appear to show any fluctuance, significant pain or spreading cellulitis. A well-healed o ld sternotomy incision. Heart: Reveals normal S1 and S2. No significant rub o r gallop. No significant pedal edema. Abdomen: Soft. Percussion is normal. Palpation does not elicit any hepatosplenomegaly, rebound, guarding, or tenderne ss. There is no flank or CVA pain. External genitalia, normal male. The patie nt does not have any inguinal adenopathy or tenderness. Musculoskeletal: Shows

no gross deformities or abnormalities. No spine pain or CVA tenderness on perc ussion. Neurologic: Deep tendon reflexes are symmetric. The patient is alert and oriented, does not exhibit any gross cranial nerve deficits. PHYSICAL EXAMINATION: This is a pleasant (XX)-year-old female who is currently sleeping comfortably in her hospital bed. The patient is easily arousable, aler t and answers questions appropriately. She is a little bit difficult to underst and. She does have some history of expressive aphasia. The patient is not sign ificantly dyspneic on conversation or on lying supine. Vital Signs: Blood pres sure is 102/43, heart rate is 95, respiratory rate 19 and saturating 96% on nonr ebreather. Skin: Warm and dry. Lower extremities: There is significant burn scarring and skin grafting visible. The patient does have her right lower extre mity bandaged secondary to chronic ulcerations. HEENT: Head is normocephalic a nd atraumatic. Pupils equal, round and reactive to light. Extraocular movement s are intact. Oropharynx is without erythema or exudate. Neck: Supple with no thyromegaly or lymphadenopathy. Lungs: Breath sounds are slightly diminished on the left base, however, without significant rales or rhonchi. There is audib le expiratory wheezing. Heart: Apical impulse is at the midclavicular line and brisk. There is no elevation of the JVP at 30 degrees. Carotids are brisk, 2/ 4 bilaterally. There are no significant bruits heard. Heart is regular rate an d rhythm. Normal S1 and S2. No significant murmurs, rubs, gallops or extra hea rt sounds appreciable. Abdomen: Soft, nondistended, nontender x4 quadrants. T here are audible bowel sounds. There are no palpable masses. Peripheral Vascul ar: Radial and femoral pulses are palpable. There are no appreciable femoral b ruits. Posterior tibial pulses cannot be palpated on the right lower extremity secondary to bandaging. Pedal pulses are diminished in the left lower extremity . Extremities are warm without clubbing, edema or cyanosis. Musculoskeletal: Unremarkable. Neurologic: The patient is alert and oriented to person, place a nd time. The patient moves all four extremities. Face is symmetric.

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/84, pulse 92, respirations 17, temperature 98.5 , pulse oximetry 98% on room air. GENERAL: The patient is awake, alert and oriented x3, although drowsy. HEENT: Normocephalic, atraumatic. Extraocular muscles are intact. Pupils are equal, round, and reactive to light bilaterally. Mucous membranes are moist. NECK: Supple. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. ABDOMEN: Active bowel sounds are present. No rebound, no guarding, no peritone al signs. EXTREMITIES: Without clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II through XII are intact. Strength is 5/5. Gait i s normal. Sensation is intact. No dysdiadochokinesia or dysmetria. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure: 122/78. Pulse: 81, regul ar. GENERAL: He is a well-nourished, well-developed (XX)-year-old male complai ning of 7/10 chest pain, who appears acutely ill. HEENT: Eyes: No scleral ict erus. No xanthelasma. Mouth: No oral pallor or cyanosis. NECK: Carotid pulse s are full and without bruit. CHEST: Clear to auscultation and percussion. CARDIAC EXAM: Cardiac impulse feels normal. Heart sounds are distant. ABDOMEN: Soft, nontender. EXTREMITIES: No edema, no varicose veins. CENTRAL NERVOUS S

YSTEM: Oriented x 3. SKIN: Cool and dry. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 124/79; pulse was recorded by triage as 122, pulse retaken by myself was 108; respirations 19, temperature 101.5. GENERAL: The patient is alert and oriented x3, in no apparent distress. HEENT: Normocephalic and atraumatic. Extraocular muscles are intact. Pupils a re equal, round, and reactive bilaterally. Tympanic membranes are intact, noner ythematous and nonbulging. Oropharynx is with some slight erythema, mild edema to the tonsillar pillars and uvula. No exudate, no submandibular anterior or po sterior auricular lymphadenopathy. NECK: Supple. LUNGS: Clear to auscultation bilaterally. No tachypnea. No difficulty breathi ng. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and nontender. No splenomegaly, no hepatomegaly, no peritoneal s igns, no rebound or guarding. EXTREMITIES: Without clubbing, edema or cyanosis. SKIN: There are no rashes noted. NEUROLOGIC: Intact and nonfocal. PHYSICAL EXAMINATION: Vital Signs: Temperature 99.6, blood pressure 156/98, pu lse 114, O2 saturation 94%. General: She is a slightly overweight woman in som e distress. HEENT: Head is normocephalic, atraumatic. Pupils are equal, round , and reactive to light and accommodation. EOMs are full. External ears are cl ear. Hearing is intact. Nasal mucosa is moist. Neck: Supple. Trachea is mid line. Thyroid is not enlarged. Lungs: Clear posteriorly, perhaps some dullnes s in the bases. Cardiovascular: Regular rate and rhythm. There is a murmur. Breasts: Not examined. Abdomen: Soft, nontender, nondistended. Hernias are n ot present. Genitourinary: Deferred. Lymphatic: Lymph nodes are not present in the neck, axilla nor groin. Musculoskeletal: She has a full range of motion , good muscle bulk and tone of all her extremities. Skin: Clear. There are no pressure wounds. Neurologic: Nonfocal. Cranial nerves are intact. Psychiatr ic: She does appear to be a little bit morose. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 142/84 with a pulse rate of 97, respiratory rate of 20, temperature of 98.6, and O2 saturation of 97%. GENERAL: The patient is alert and oriented x4, in no acute distress. Does not a ppear toxic or ill. HEENT: Pupils are equal, round, and reactive to light. Extraocular movements a re fully intact. Oropharynx is clear. No erythema. Uvula is midline. Tonsils are inflamed with a slight amount of exudate. Palate is even. HEART: Regular rhythm. No murmur, rub or gallop. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds. EXTREMITIES: Have no clubbing, cyanosis or edema. PSYCHIATRIC: The patient is alert and oriented x4. VASCULAR: Has good pulses throughout. LYMPHATICS: The patient does have lymphadenopathy along the anterior cervical c hain. SKIN: Warm, dry, and intact. PHYSICAL EXAMINATION: GENERAL: This is a pleasant male in no acute distress. VITAL SIGNS: Blood pressure 114/86 and pulse 82. Afebrile.

HEENT: Sclerae anicteric. Pupils are equal and reactive. Oropharynx clear. T ongue normal size. NECK: Supple. No adenopathy or thyromegaly. Carotids 2+ and symmetrical. LUNGS: Clear to auscultation and percussion. Negative spinal tenderness. Nega tive CVA tenderness. ABDOMEN: Soft. There was no distention. No guarding, rigidity, organomegaly o r masses. Normal bowel sounds without tympany. There was mild to moderate epig astric tenderness to deep palpation. EXTREMITIES: Femoral pulses 2+, symmetrical. No clubbing, cyanosis or edema. Distal pulses 2+, symmetrical, dorsalis pedis and posterior tibial. NEUROPSYCHIATRIC: Alert and oriented x3 without focal defects. PHYSICAL EXAMINATION: GENERAL: The patient is well developed, well nourished and in no acute distress . VITAL SIGNS: Weight 201 pounds; height 5 feet 6 inches; BP 153/92, left arm, an d 140/86, right arm; pulse 82 and regular; respirations 18 and unlabored. HEENT: Normocephalic and atraumatic. PERRL. EOMI. No lid lag, no exophthalmo s, no xanthelasma, conjunctivae pink, no scleral icterus. Ears and nose externa lly normal. Pharynx normal. Has upper dentures. NECK: No JVD. No carotid bruit, no thyromegaly, no adenopathy. CHEST: Lungs clear. Breath sounds normal bilaterally. HEART: PMI in the fifth intercostal space, no lift or thrill. S1 and S2 normal . No gallop, murmur or rub. Had 2/6 systolic ejection murmur diffusely, both a t the base and at the apex. ABDOMEN: Soft and nontender. Normal bowel sounds. No bruit. No palpable aort ic aneurysm, mass or organomegaly. EXTREMITIES: Full range of motion. No cyanosis, clubbing, trace edema. MUSCULOSKELETAL: No gross joint deformity or swelling. NEUROLOGIC: Alert and oriented x3. Cranial nerves intact. Balance, gait, and coordination normal. Normal affect. SKIN: No significant skin lesions or rashes. PSYCHIATRIC: Mentation normal. PHYSICAL EXAMINATION: Reveals a well-developed, well-nourished female who is in no acute distress. Her vital signs are stable. Respirations are 20. Head, ey es, nose, and throat are within normal limits. Lungs are relatively clear. Som e decreased breath sounds at the bases. Heart revealed no murmur, gallop or rub . Abdomen is not significantly distended. Bowel sounds are present. There is a scar from the xiphisternum all the way down to the lower pelvis. It was not s ignificantly tender. There were two small incisional hernias that were not inca rcerated. No organomegaly or masses. No bruits in the abdomen. Extremities re veal no clubbing, cyanosis or edema. Rectal reveals nonimpacted stool which is Hemoccult negative by my testing. Neurologic is grossly intact. PHYSICAL EXAMINATION: General: The patient is drowsy. He is arousable. He is unable to answer questions. He is not moving the left half of his body. Vital Signs: His pulse on arrival was 76, blood pressure was 129/66, respirations no rmal, and temperature normal. HEENT: Normocephalic. No pallor, jaundice or xa nthelasmata. Neck: Supple. Arterial and venous pulses were normal. Chest: V esicular breathing with slightly prolonged expiration. Heart: Regular, first n ormal, and second split normally. There is a soft murmur, 1/6, apex. There is no rub. Abdomen: Soft and nontender. No rebound tenderness, organomegaly or a scites. Normal bowel sounds. Extremities: Shows no edema. Neurologic: There is left hemiplegia.

PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished white female in no acute distress. Ale rt and oriented x3, nontoxic in appearance. The patient is ambulatory in the em ergency department. HEENT: Noncontributory to exam. NECK: Supple without lymphadenopathy. No JVD or bruits noted. HEART: Regular rate, regular rhythm without murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi. ABDOMEN: Soft and nontender. No rebound, no guarding, no hepatosplenomegaly, n o masses noted. BACK: Negative CVA tenderness. EXTREMITIES: The patient has 2+ pulses in all extremities. Full range of motio n of all extremities. No ecchymosis, edema, erythema, clubbing or cyanosis note d on the left side, but in the right upper extremity, the patient does have posi tive edema to her entire arm. It is cold to touch and pale in color. The patie nt also has positive bruising on the medial aspect of the humerus and the forear m. She has full range of motion but complains of pain in the elbow with range o f motion. SKIN: Warm and dry to touch, except to the right arm. The patient's entire rig ht arm is cold to touch and pale in color. NEUROLOGIC: The patient is alert and oriented x3. The patient has 5/5 strength in all extremities, 2+ deep tendon reflexes, equal, throughout extremities. Gr oss sensation to touch is intact. Cranial nerves II through XII grossly intact.

PHYSICAL EXAMINATION: VITAL SIGNS: On physical exam today, the patient had a pulse of 74, blood press ure 132/85, respiratory rate of 17. GENERAL: The patient is a well-developed, well-nourished female in no apparent distress. HEENT: EOMI. PERRL. No conjunctival erythema. No scleral icterus. External Ears and Nose: No evidence of lesions or trauma. Oropharynx is clear and moist . NECK: Supple, 2+ carotids bilaterally. No bruits. No lymphadenopathy. No JVD . No thyromegaly. LUNGS: Clear to auscultation and percussion. Normal respiratory effort. HEART: Regular rate and rhythm. S1 and S2. No S3 and S4. No murmurs, rubs, o r gallops. ABDOMEN: Bowel sounds positive, soft, and nontender. She had no hepatosplenome galy. EXTREMITIES: She has no lower extremity edema. NEURO: Alert and oriented x3. Strength 5/5 bilaterally on upper and lower extr emities. Sensation intact grossly to light touch and pinprick. No evidence of dysmetria on finger-to-nose. No shuffling and no wide-based gait. PSYCH: Alert and oriented x3, mood good, no flat affect. MUSCULOSKELETAL: Gait and station is somewhat awkward. She did have some troub le getting around. PHYSICAL EXAMINATION: Temperature: Afebrile. Vital signs are stable. The pup ils are equal, round, and reactive to light and accommodation. Extraocular musc le function is intact. The sclerae are clear. There is no mucosal pallor or mu cositis. The tympanic membranes are intact. The nose is patent. The oropharyn x reveals no erythema or edema. The tongue is midline. No sinus tenderness. T he neck is supple without masses. The trachea is midline. The carotid pulses a re full with no overlying bruit. There is no thyromegaly. There is no cervical , supraclavicular, axillary or inguinal adenopathy. The cardiac exam reveals a regular rate and rhythm without murmur, rub or gallop. The lungs are clear to a

uscultation and percussion. The abdomen is soft and nontender. No hepatomegaly , splenomegaly, tenderness, mass or ascites. Extremities with arthritis. The n eurologic exam reveals no cognitive dysfunction, focal neurologic deficits, path ologic reflexes, cerebellar signs or gross sensorimotor deficits. The cranial n erves II through XII appear grossly intact. The skin is normal with no suspicio us lesions or rash. PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is alert and oriented, n ot in any acute respiratory distress. VITAL SIGNS: Afebrile. Pulse is 82 per minute, respiratory rate is 21 per minute, and blood pressure is 126/70. HEENT: PERRLA. EOMI. No icterus. NECK: Supple. There are bilateral lymph nodes p alpable on both sides of the cervical area. No enlarged thyroid. No JVD. Muco us membranes are normal. HEART: S1 and S2 regular. No murmur heard. CHEST: Bilateral air entry. No rhonchi, no rales. ABDOMEN: Soft and nontender. Live r and spleen clinically not palpable. Bowel sounds are present. No guarding, n o rigidity, and no rebound. EXTREMITIES: Left extremity positive for edema. B ilateral pulses are seen. Petechiae are seen on the left lower extremity. BACK : No local tenderness. No CVA tenderness. NEUROLOGIC: No focal deficit. SKI N: Other than the petechial rash on the legs, no other skin or ecchymotic lesio ns seen. LYMPH NODES: Enlarged lymph nodes are palpable in the cervical area, both axillary areas, and left inguinal area. Lymph nodes are not matted and non tender. No overlying erythema, and all the lymph nodes are mobile. PHYSICAL EXAMINATION: GENERAL: A well-developed, well-nourished white man in no acute distress. VITAL SIGNS: Blood pressure is 154/60, heart rate is 80 and regular, respirator y rate 20 and unlabored, and temperature is afebrile. SKIN: Without rashes. HEENT: Normocephalic and atraumatic. The conjunctivae are anicteric. The orop harynx is without lesions or exudate. The tongue is midline. The gag is intact . Poor dentition is noted. NECK: Supple. Full range of motion. No thyromegaly or adenopathy. Carotids a re 2+ without bruits. There is mild JVD appreciated. CHEST: Reveals decreased breath sounds at the left base with egophony appreciat ed. No rales, rhonchi, or wheezes. There is decreased, but symmetric air expan sion. HEART: Regular rate and rhythm. Normal S1 and S2. No murmur, rub, or gallop a ppreciated. ABDOMEN: Soft, nontender, and nondistended. No hepatosplenomegaly. No rebound or guarding. EXTREMITIES: Demonstrate 1-2+ pitting edema with greater edema appreciated in t he left lower extremity. No palpable cords. NEUROLOGIC: Grossly nonfocal with no lateralizing motor deficits. PHYSICAL EXAMINATION: VITAL SIGNS: Currently, her blood pressure is 160/94, te mperature 96.4, respiratory rate 22, and pulse oximetry 98% on room air. HEENT: Conjunctivae are clear. Oropharynx is slightly dry but clear. LUNGS: Clear. NECK: No lymphadenopathy in the neck or supraclavicular region or axillary re gion. No evidence of lumps in the breasts or nipple discharge. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender without hepatosplenomegaly. EXT REMITIES: Muscle strength is 5/5 proximally and distally in the extremities. D TRs are +2 at the elbows and zero at the Achilles. Babinski equivocal. Pulses are decreased, PT and DP. There is evidence of chronic erythema of the skin abo ve the medial malleolar, on the left. It is nontender. Evidence of mild OA cha nges of the hands, knees, arms, and feet. There is marked tenderness of the low er thoracic upper lumbar region. There is evidence of marked kyphosis of the th oracic spine.

PHYSICAL EXAMINATION: VITAL SIGNS: Stable. She is afebrile with temperature of 98.5 and blood pressur e of 154/95. HEENT: Showed no scleral or conjunctival inflammation. Her oral mucosa was mois t without lesions. NECK: Supple without lymphadenopathy or thyromegaly. The carotid upstrokes were 2+. She had no salivary gland swelling or tenderness. Her carotids were nontend er with no bruits. She had no supraclavicular or infraclavicular bruits. The tem poral arteries were nontender and nonnodular with normal pulsations. Radial and dorsal pedal pulses were 2+. LUNGS: Had no rales, rhonchi, or wheezes. CARDIAC: Had no murmur. ABDOMEN: Nontender without organomegaly. It was somewhat distended and misshape ned after her colectomy. SKIN: Had no rash. She had onychomycosis but no nail pitting. She had no nail f old capillary changes. No sclerodactyly. She had scalp alopecia but was wearing a hair piece. She had no subcutaneous nodules or gouty tophi. NEUROLOGIC: Grossly intact. MUSCULOSKELETAL: Notable for some pain with palpation of the posterior neck mus culature and diminished range of motion in the neck. The spine was nontender. Sh oulders, elbows, and wrists were normal. The left third DIP, left second PIP, an d right fourth PIP had swelling, tenderness, and erythema. The right third MCP h ad a small nodule which was significantly tender. Her right hip had significant pain with active flexion. Passive range of motion of hip while not full was not nearly as painful. Both knees had osteoarthritis with no active synovitis. Her a nkles were not tender. All of her toes had cock-up deformities with no active sy novitis.

SAMPLE MT PHYSICAL EXAM SECTION EXAMPLES: PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 126/94, pulse 66, respiratory rate 22, and temperat ure 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 ul cers 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. ABDOMEN: Soft. EXTREMITIES: No edema. MUSCULOSKELETAL: The patient has somewhat limited range of motion of her should ers, elbows, hips, and knees, primarily due to previous paralysis, with basicall y 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. H EENT: Shows no icterus. No petechiae. Pupils are reactive to light and accomm odation. Conjunctivae and sclerae are normal. The nose is normal. No ulcerati ons. No dryness in the mouth. There is no mucositis. No yeast patches. No he rpetic sores. The throat shows no abnormalities. NECK: Supple. No neck vein distention. Carotid pulses are normal. The neck veins are flat. CHEST: The c

hest is symmetric. LUNGS: Clear to auscultation and percussion. No wheezes. No rhonchi. There are just decreased breath sounds in the bases. HEART: Tachy cardic, 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 extre mities show no peripheral edema. No muscle tenderness. No arthritis. No phleb itis. 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 wit h no signs of infection. There is also a Port-A-Cath in the left subclavian are a which is not red, hard, or swollen at the present time. NEUROLOGIC: The neur ological exam is unremarkable. She is alert, oriented. No neurological changes . No cranial nerve involvement.

PHYSICAL EXAMINATION: Temperature 98.6, blood pressure 158/96, oxygen saturatio n 98%, and heart rate 90. General: He is alert and oriented x3, in moderate acu te distress secondary to pain. HEENT: Within normal limits. Chest: No respirat ory 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 v olar aspect with superficial swelling and a white fluctuant area that is very pa inful to palpation. He also had some pain with passive motion of the small finge r and ring finger. He had no pain with passive motion of his middle, index or th umb. No pain with active motion of his wrist. He has an erythematous painful swe lling with draining pustule on the hypothenar eminence. He has 2+ radial pulse o n that side and brisk capillary refill. Neurological: General neuro exam is with in 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: T he 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 ausc ultation. Cardiovascular: Regular rate and rhythm with murmur, 2+ pulses. Abdom en is soft, obese, nontender, nondistended. Positive bowel sounds. Positive stri ae. Difficult to palpate spleen secondary to obesity. Extremities: Warm, well p erfused. No clubbing, cyanosis or edema. Knees are noted to not be edematous wit hout effusion and nonerythematous bilaterally with normal range of motion. Negat ive anterior drawer. Does have pain upon palpation of the patella bilaterally. N eurologically, the patient is able to ambulate well. Has normal tone and althoug h cognitively appears slow was able to respond to questions.

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 s aturation 96%. Head is normocephalic and atraumatic. Pupils are equal, round, re active 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 lef t side with some guarding and some decreased bowel sounds. Had a rectal exam tha t was heme positive. Back: No CVA tenderness. Skin is warm and dry. No rash. Ex tremities: No clubbing, cyanosis or edema. Good pedal pulses bilaterally. Deep tendon reflexes appear grossly intact, 2/4 upper extremity and lower extremity b ilaterally. 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 pat ient is an (XX)-year-old gentleman in no acute distress, on oxygen. HEENT: Pup ils are equal, round, reactive to light and accommodation. Extraocular muscles intact. No tenderness on palpation over the temporal arteries. CHEST: Bilater al breath sounds. HEART: S1 and S2. ABDOMEN: Soft. EXTREMITIES: No edema a nd no cyanosis in the lower extremities. In the upper extremities, the right wr ist joint has obvious swelling and also redness and increased temperature. The patient is unable to move the right upper extremity freely because of the discom fort in his wrist joint. Left shoulder seems to be moving fine. Elbow joint ap pears 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 f eet. There is no tenderness on palpation over the MTP joints. Motor power appe ars to be good in the left upper extremity and the lower extremities. NEUROLOGI C: Neurologically, the patient is alert and oriented.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: This is a pleasant (XX)-year-old fem ale presently in no acute distress. The patient is alert and oriented x3, pleas ant, and cooperative with the examination. Height is 5 feet and 6 inches, weigh t 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 ar e equal and reactive. ENT: Unremarkable. Tongue is midline. Mucosa is moist. NECK: Supple. No JVD. No lymphadenopathy. No carotid bruits. LUNGS: Clea r with no rales, wheezes, or rhonchi. HEART: Reveals regular rhythm/bradycardi c rhythm. S1 and S2 intact. There is a soft grade 1/6 systolic murmur noted al ong the left sternal border. CHEST: Sternotomy scar is well healed. ABDOMEN: Soft and nontender. Positive bowel sounds. EXTREMITIES: Free of edema, cyano sis, or clubbing. Pulses reveal 2+ radial pulses. Femoral pulses are 2 to 3+ b ilaterally with no femoral bruits. Dorsalis pedis pulses 1+ bilaterally. Muscl es, 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 press ure 132/74, pulse 76, respiratory rate 22, and temperature is 97.4. HEENT: Hea d is atraumatic. Pupils are equal and reactive to light and accommodation. Ext raocular muscles are intact. Sclerae clear. Lips not cyanotic. Palate normal. Pharynx is normal. Tonsils not enlarged. Buccal mucosa without any pigmentat ion. Tongue and mouth, dry. Neck supple. Negative JVD. Trachea is central. Thyroid is not enlarged. CHEST: Normal expansion. No crepitation. No fremitu s. No tenderness on palpation. Bilateral air movement with no wheezing. No rh onchi. No dullness to percussion. No use of accessory muscles. No intercostal muscle retraction. Basilar crackles. HEART: Regular rate and rhythm. S1 nor mal. S2 physiologic split. Negative S3. No prominent P2. No murmur appreciat ed. ABDOMEN: Obese, soft, and nontender. Bowel sounds are positive. No orga nomegaly. EXTREMITIES: Negative cyanosis. Negative clubbing. Trace edema. P ositive pulses. NEUROLOGIC: Neurologic examination is intact. RECTAL/PELVIC/B REASTS: Exam deferred. SKIN: Without any rashes. --------------------------------------------------------------------------------------------------------------

PHYSICAL EXAMINATION: The patient is a well-developed, mildly obese male who ap pears to be in no acute distress. Blood pressure 108/72, heart rate 102, and Tmax 102. HEENT: Head is normocephalic. Neck: Soft and supple. Thyroid is mi dline and nonnodular. No carotid bruits are noted on auscultation. Lungs: Cle ar to auscultation throughout and somewhat diminished in the left base, with mil d bronchovesicular breath sounds in the lower left fields. Respirations are unl abored at present. Heart: Rhythmic and regular without any murmurs, gallops or rubs. There is no jugular venous distention. No hepatojugular reflux. The PM I is nondisplaced. Abdomen is soft and nontender. Bowel sounds are present th roughout. Musculoskeletal: The patient has no unilateral muscle wasting. No j oint effusions or erythema. Neurological: The patient is alert and oriented wi th no focal neurological deficits noted on inspection. Peripheral Vascular: Do rsalis pedal pulses and posterior tibial pulses are intact bilaterally, and ther e is no pitting or pedal edema.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: This is an (XX)-year-old gentleman w ho appears to be answering appropriately and appears to be alert to place and pe rson. VITAL SIGNS: Blood pressure 126/59, heart rate 84, respirations 22, temp erature 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 implantat ion bilaterally. Teeth are in poor repair. Uvula is midline and tongue appears slightly pink and dry. NECK: Supple. No thyromegaly noted. There is some ju gular 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+ bi laterally. There is no peripheral edema. NEUROLOGIC: Neurologically, there ar e no focal deficits noted.

PHYSICAL EXAMINATION: VITAL SIGNS: The patient's vital signs on admission; tem perature 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 normoc ephalic and atraumatic. Extraocular muscles were intact. No scleral icterus. No throat erythema or exudates. NECK: Supple. No lymphadenopathy. Mild JVD w ith hepatojugular reflex. LUNGS: Bibasilar rales were noted. No wheezes or rh onchi. HEART: S1 and S2 present and tachycardic 2/6 systolic murmur noted on t he left upper sternal border, more pronounced in the mitral valve area. No rubs or gallops. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sound s. GENITAL AND RECTAL: Deferred. EXTREMITIES: No clubbing, cyanosis or edema . NEUROLOGIC: The patient was awake, alert, and oriented x3. Cranial nerves I I 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 n o apparent distress. Skin. No rashes or lesions. Head was normocephalic, atra umatic. Pupils were equally round and reactive to light. Throat was clear. Ne ck: Mild JVD. No lymphadenopathy. Chest: Nontender. Heart: S1, S2 present. No murmurs, rubs or gallops. Lungs were clear to auscultation. Abdomen was s oft, nontender, nondistended. Bowel sounds were present. Genital and rectal ex

aminations were deferred. Musculoskeletal: No joint pain or point tenderness. Extremities: No clubbing or cyanosis. Trace pedal edema bilaterally. Neurolo gically, 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 1 14 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 ref lex bilaterally. Throat: Negative. Neck: Negative. Lungs: Clear to auscultation. Heart: Regular rate and rhythm. Breasts: Tanner V. No masses bilaterally. Abdom en: 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 poun ds, 90-95th percentile. BMI is 27.9, more than 95th percentile. Blood pressure i s 110/66. General Appearance: The patient is healthy looking but overweight, is pleasant and interactive. HEENT: Both tympanic membranes are clear. Both conju nctivae are clear. Nose: Clear. Nasal turbinates are not swollen. Throat is cle ar. Mouth is clear. There is no neck mass. Chest/Lungs: Good air entry with cle ar 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. Extremit ies: 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. Gene ral Appearance: This young man appears to be a well-nourished, well-developed ma le. HEENT: Eyes: Positive red reflex. Disks clear and sharp. EOMI. Pupils are e qual, round and reactive to light and accommodation. Nose: Clear. Throat: Clea r. Ears: TMs clear bilaterally. Neck: Supple, no thyromegaly. Chest: Clear to A and P. Spine: No scoliosis. Abdomen: Soft, no masses. Bowel sounds present. Ext ernal Genitalia: Tanner IV. Testes descended bilaterally, normal male, normal sc rotum. Extremities: Good femoral pulses, +2 bilaterally. Skin: Normal. Neurologi c: 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 12 2/74. Height 5 feet 4 inches and weight 276 pounds. HEENT: Pupils are equal, ro und and reactive to light and accommodation. Sclerae anicteric. Oral cavity mois t and pink. Tongue protrudes midline, 1+ to 2+ tonsillar hypertrophy without cry pt exudate or obstruction. Neck: Supple. No JVD, adenopathy or thyromegaly. Lun gs: Clear to bases bilaterally. Heart: Regular rate and rhythm. No S3, S4, mur mur or carotid bruits. Abdomen: Centrally obese. Distant bowel sounds in all qu adrants. Organomegaly not appreciated secondary to body habitus. No tenderness, masses, rebound. Rectal exam deferred. Peripheral Vascular: Extremities warm an d dry without edema. Musculoskeletal: Muscle strength 5/5, all major muscles. N eurologic: Motor strength 5/5, all major muscles. Sensation intact to light tou ch 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 di stress. 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. Ext remities: Within normal limits. Skin: Did have initially a glabellar salmon patc h, but that is fading. Neurologic: She is very alert. DTRs are equal. Cranial ne rves are intact, nonfocal.

PHYSICAL EXAMINATION: In general, this is a well-developed, overweight, confron tational male who appeared to be somewhat agitated and frustrated. He had a bloo d pressure of 122/84, pulse of 68, respirations of 18. He had very significant p ain behavior. He appeared very distracted and had a blunt affect with a depresse d mood. He had very poor eye contact. On structural exam, the patient had a thor acolumbar scoliosis, which is compensated. He had protraction of the neck and sh oulders with postural syndrome. He had decreased range of motion in all planes o f the cervical, thoracic, lumbar regions including the shoulders due to signific ant kinesophobia and guarding. He had multiple trigger points throughout the cer vical and thoracolumbar fascia. He had generalized tenderness throughout the axi al spine, however, nonfocal. There was no step-off deformity. Distal vasculature is otherwise intact and symmetric. He had multiple skin abrasions, which were a ll chronic. He did not have any tract signs on his arms. There was tenderness ov er the sacroiliac joint region, however, nonfocal. Sacroiliac provocation tests were equivocal. Neurologic exam of the upper and lower extremities; intact to mo tor power. This included intrinsic hand as well as intrinsic shoulder musculatur e. 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 compres sion was positive for neck and low back pain. Finger-to-nose was intact and Romb erg 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 d istress. Her height is 5 feet 4 inches, weight 166 pounds, and blood pressure 12 2/84. She rates her pain as 0 on a scale of 1-10. Her lymph node survey is unrem arkable. No supraclavicular, axillary or inguinal nodes palpated. Her breast exa m 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 a nd discharge. Cervix was well visualized, smooth with no CMT. ThinPrep Pap was o btained. Cervix was slightly stenotic. Bimanual exam revealed no masses and no t enderness. 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. Tym panic membranes are normal. There is some cerumen in the right canal, which was syringed and removed. Throat is normal. Carotids: No bruits. Thyroid not enlarg ed. Lungs: Clear. Breasts: Negative. Heart: Regular rhythm. No murmurs. Abdom

en: Soft, no tenderness, no masses. Bimanual/Pelvic: Normal uterus. Ovaries no t 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 in ches. Weight is 180. His cardiac examination shows normal sinus rhythm. There st ill is a grade 1/6 systolic murmur down the left sternal border, but no cardiome galy. The lungs are clear without rales. He has no pedal edema. He still has a m inute 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 limi tation of his right hip on internal and external rotation. His left shoulder als o is tight on external rotation. I feel no hernia. Prostate exam shows a small s oft prostate without nodularity. His peripheral pulses are excellent. The right is bounding at +2. The left is only slightly less forceful. Carotids are +2 with out bruits.

PHYSICAL EXAMINATION: On exam, she is an obese woman who looks approximately he r stated age and does not appear to be in any acute distress. Vital signs inclu de 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 correct ive lenses. Mucous membranes are moist. Tongue and nasal septum appear to be i n 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 thyrom egaly. She has no carotid bruits. Her chest is clear to auscultation bilateral ly. 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 obes ity. She has a grade 1 to 2 pannus. There are no surgical scars. She has no ev idence of abdominal wall hernias. Her abdomen is nontender with no discernible hepatomegaly or splenomegaly. In addition, she does not appear to have any abdo minal masses. However, her abdominal exam is somewhat limited because of her obe sity. Lymphatic: She has got no discernible cervical, axillary or inguinal lym phadenopathy. Musculoskeletal: She ambulates without assistance and her gait a ppears to be grossly normal. Extremities: There is no evidence of clubbing, cy anosis or edema on her lower extremities. Skin: There is no evidence of curren t 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 n eck is supple. Her mucous membranes are moist. Her lungs are clear to auscultati on bilaterally. Her heart is regular rate and rhythm. She has no evidence of spi nal tenderness. Her abdomen is soft and nontender without evidence of hepatosple nomegaly. Her extremities are without clubbing, cyanosis or edema. Neurologicall y, she is alert and oriented x3. Her breasts are moderately large, pendulous, an d 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 s kin changes bilaterally. I could not appreciate any concerning dominant masses i n either breast.

PHYSICAL EXAMINATION: On physical exam, the patient is an alert and oriented wo man, in no acute distress. Neck is supple without masses. There is no thyromegal y. There is no cervical, supraclavicular or axillary adenopathy. Lung sounds are clear to auscultation. Cardiac exam reveals regular rate, S1 and S2, without an y evidence of murmur, rub or gallop. Skin overlying the breasts reveals well-hea led surgical incisions in the 6 o'clock position of the breast. There are telang iectases at the surgical scar. Otherwise, skin is intact without dimpling or puc kering. Nipples are everted and without discharge. Examination of the right brea st 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 v ertebral 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 accommod ation. Extraocular movements are intact. Oropharynx: Without erythema or exudat e. Neck: Supple, no lymphadenopathy, no thyromegaly. Chest: Clear to auscultat ion. Heart: S1, S2. Rate and rhythm are regular. No murmurs, gallops or rubs. A bdomen: Soft, nontender, normal bowel sounds. No hepatosplenomegaly. Extremitie s: Without edema. Distal pulses 2+ bilaterally. Breasts: No masses, skin chang es, nipple discharge or axillary lymphadenopathy. Examination of the right shoul der 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 gr oomed, 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. N eurologically, 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 i s 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 recal l 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 perf orm simple calculations. She can copy intersecting pentagons, but not a cube. Sh e 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 wri te. Cranial nerve examination reveals small pupils bilaterally, which are reacti ve 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 accomm odate. Visual fields are full. The face is symmetric in movement and sensation. Hearing is grossly diminished to conversation bilaterally. The palate elevates s ymmetrically. 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 norm al. There are no frontal motor release signs. Deep tendon reflexes are 2+ symmet rically at the knees, 1+ symmetrically in the upper extremities. I cannot elicit ankle jerks. She has withdrawal bilaterally to plantar testing. Sensory examina tion is notable for diminished pinprick and vibration in the distal stocking dis tributions bilaterally. Temperature sensation and joint position sense are well preserved. There is no extinction to double simultaneous stimulation. Finger-tonose 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 g ait is done with a cane. She is unsteady and has some scoliosis, tending to lean her trunk towards the left.

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: N ormocephalic. Pupils are equal, round and reactive to light and accommodation. E OMs grossly intact. He wears corrective lenses. Mucous membranes are moist. Tong ue and nasal septum appear to be in the midline. Neck is supple with no lymphade nopathy and no thyromegaly appreciable. Chest is clear to auscultation bilateral ly. Heart: No murmurs, no gallops. Abdomen is flat, soft, nontender. No hepatome galy, no splenomegaly, and no abdominal masses are appreciable. His external gen italia 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 eviden ce of clubbing, cyanosis or edema. Musculoskeletal: He ambulates without assista nce and his gait appears to be grossly normal. Neurologic: He is awake, alert, a nd oriented x3.

PHYSICAL EXAMINATION: Vital Signs: Heart rate 72, blood pressure 132/80, and r espiratory rate 16. General: He is a pleasant male in no acute distress. HEENT: Normocephalic. No nuchal rigidity. Cardiovascular: Normal S1, S2, regular rat e and rhythm. No carotid bruits. Lungs: Clear to auscultation bilaterally. Neur ologic: Mental Status: He is alert and oriented x3. He has fluent language wit h intact comprehension. There is no left/right confusion, neglect or apraxia. Re cent and remote memory intact. Cranial Nerves: Pupils are equal, round, and rea ctive to light. Funduscopy is negative for papilledema. Extraocular movements ar e intact without nystagmus. Visual fields are full to confrontation. Face is sym metric with full strength and sensation. Hearing is conversationally intact. Pal ate elevates symmetrically. No dysarthria. Sternocleidomastoid and trapezius, fu ll strength. Tongue protrudes midline. Motor exam: Normal tone and bulk, 5/5 str ength 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 proprioceptio n in the toes. Sensation is intact to light touch, temperature, and pinprick thr oughout. Coordination: No dysmetria on finger-to-nose, heel-to-shin, rapid alter nating movements. Gait: He has a steady, narrow -based gait. He is able to toe w alk, heel walk and do tandem gait without difficulty. Romberg is negative.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.5, heart rate 72, respirator y rate 20, blood pressure 124/82, and O2 saturation 100% on nasal cannula. GENE RAL: 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: Mu ltiple facial lacerations and a lip laceration. HEENT: Pupils are equal and ro und 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 an y broken teeth. There is a laceration noted to the right upper lip. This is ve ry small, measuring only 0.5 cm in length. There does not appear to be any sign ificant injury to the interior of the mouth. Nose is somewhat swollen. There i s 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 r egion. 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 roll ed on his side in cervical spine precautions and he was not noted to have any de formity or step-off in the back, but told me he had tenderness throughout the en tire back. HEART: Regular rate and rhythm. LUNGS: Clear and equal bilaterall y. 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 t he 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 pound s. Room air saturation is 96%. GENERAL APPEARANCE: The patient is a (XX)-year -old male. Well developed and well nourished. HEENT: Normocephalic and atraum atic. 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 a ppearing. Thyroid without masses or nodules. No adenopathy and full range of m otion. RESPIRATORY: Breath sounds were clear, full inspiration. No wheezes, r ales, or rhonchi. CARDIAC: Regular rate and rhythm, S1 and S2. No murmurs, ru bs or gallops. No carotid bruits. ABDOMEN: Soft and nontender. No masses. N o renal or aortic bruits. No organomegaly. Bowel sounds were present. GENITOU RINARY: 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 lymphadenop athy. NEUROLOGIC: Cranial nerve I: Sense of smell intact. Cranial nerve II: Visual acuity normal. Pupils equal, round, reactive to light, and accommodatio n. Fundi were benign. Cranial nerves III, IV, and VI: EOMI. Cranial nerve V: Full facial sensation bilaterally and clinches jaw. Cranial nerve VII: Smile s, 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 re sistance. Cranial nerve XII: Tongue protrudes midline. No atrophy or fascicul ations to resting tongue. Motor sensory: Equal muscle strength in all groups t ested. No atrophy or fasciculations. Intact pain and light touch, propriocepti on, and stereognosis. Rapid alternating movements intact. Normal gait. Heel w alking and toe walking were normal. Romberg was negative.

COMPLETE OFFICE PHYSICAL S: The patient presents for a physical. His main problem has been some pains in the neck, elbows and lower back. The back pain has been present for just a few d ays and is slightly worse with movement. He has had pains in his elbows for appr oximately four months. It is relatively constant, no extreme. It does tend to hu rt when he supinates his forearm fully. He has also had some mild pain in the ba ck. At one time, he was thought to possibly have cervical disc disease; however, a CT scan of the cervical spine was unremarkable. He has no other significant h istory. Social: He is a nonsmoker. Family history: His father does have some mil d arthritis and also has hypertension and heart disease. O: HEENT: Tympanic membranes are clear bilaterally. Nose and throat are clear. N

eck is supple without lymphadenopathy or bruits. Cardiovascular: Regular rate an d rhythm without murmur. Abdomen: Soft, flat, nontender, and nondistended. Bowel sound are active. He has some minimal tenderness in the right lower quadrant. B ack: There is trigger-point tenderness. Lower extremities are normal to exam. He has negative straight leg raising in the supine position. Laboratory studies were within normal limits, with the exception of his choleste rol which was 236 and his triglycerides which were 320. He is not watching his d iet at all. A: Strain of the lower back. I think this may well be due to his work as a clerk . He spends a lot of time at a computer keyboard. P: He is to take the strain off of his elbows and lower back. I also gave him an instruction sheet on a low-cholesterol diet. He will try to follow this for six months, and we will recheck his cholesterol then. He asked if I would recommend taking niacin. I told him that it might have some beneficial effect and was pro bably relatively safe for him to take. Return to top ETOH REHAB NOTE CHIEF COMPLAINT: The patient is a 46-year-old Caucasian male admitted to detox o n _____________ with the patient stating, "I'm at the end of my rope." HISTORY OF PRESENT ILLNESS: He admitted to using fentanyl patches for six months as well as taking 20 to 30 Lorcet daily for at least three months, smoking 1 pa ck of cigarettes daily, and drinking 3 beers and/or 3 to 5 mixed drinks per day. He had been treated eight years ago for anxiety and depression and was treated also prior to admission with Remeron but had not taken it since_________________ _. He had three prior detoxes previously. REVIEW OF SYSTEMS: There was no history of hepatitis or sexually-transmitted dis eases. Allegedly, he had a negative HIV test in the last few years but was not s ure of the date. He denied any history of cardiovascular disease or diabetes. He complained of nausea and vomiting. His weight had been stable in the preceding six months. He admitted that he had been taking apart the fentanyl patches, whic h had been prescribed for his back pain, and had been sniffing the active ingred ient off of the patch. SOCIAL HISTORY: He had no current legal issues. He was married and living with h is wife but questioned whether or not she was really supportive of his problems. He was a full-time employed ______. FAMILY HISTORY: He denied any family history of addiction. PAST MEDICAL HISTORY: He used an albuterol inhaler for a diagnosis of "asthma." He had had a laminectomy in ____ and three surgeries on his left ankle in ____, ____, and ____. PHYSICAL EXAMINATION: General: He appeared as a heavy-set, weepy male smelling o f alcohol. He blew a 0.6 on the Breathalyzer. Vital Signs: Height was 6 feet. We ight was 265 pounds. Temperature was 97.9?F. Blood pressure was 128/78. Pulse wa s 108. Respirations were 18. HEENT: Head was atraumatic. There was no icterus or cyanosis. Neck: Not unusual. Lungs: Slightly decreased breath sounds. Heart: So unds and rhythm normal. Abdomen: Very obese, nontender, no masses, and no liver, spleen or kidneys palpable. Extremities: He was wearing a bandage on his left h and due to a recent tendon repair over the laceration. X-RAY and LABORATORY FINDINGS: Liver enzymes were normal. Albumin was 5.3. MCV w as 97, the remainder of his CBC was normal. RPR was nonreactive.

HOSPITAL COURSE: Treatment was with sublingual and transdermal clonidine. He als o required albuterol for some bronchospasm, Ultram for withdrawal cramps, Phener gan for nausea, and Imodium for diarrhea. He attended group and individual couns eling sessions and appeared to participate well. CONDITION ON DISCHARGE: Improved. DISCHARGE DIET, ACTIVITY, and FOLLOW-UP INSTRUCTIONS: He is discharged today to follow up with outpatient therapy on _______ at ____ p.m. DISCHARGE DIAGNOSES: 1. 2. 3. Acute and chronic addiction to opiates, alcohol and nicotine. Chronic obstructive pulmonary disease, mild. Lumbar discopathy, status post laminectomy.

Return to top TYPICAL SOAP NOTE (subjective, objective, assessment and plan) S: This is a 78-year-old white female with multiple complaints. She has a histor y of chronic sinusitis, esophagitis, a fibromyalgia-type syndrome, and depressio n. She complains today of continued problems with pain in the left cheek and pre auricular area, especially in the morning. The pain gets very intense at times. She also has a great deal of postnasal drainage which gives her a sour feeling i n her stomach. She also complains of some dizzy spells over the last few months, usually when she is working around the house. These are associated with some sw eating and nausea. She has not ever had any loss of consciousness. She also comp lains of recurrent problems with constipation, especially over the last three mo nths. She has been using Correctol. This tends to give her runny stools for a da y and then she has constipation again the next day. She has tried taking Colace. This was not helpful. O: General: She is a well-nourished, well-developed, elderly white female in no acute distress. She appears somewhat sad and tearful. HEENT: Tympanic membranes were clear bilaterally. Nose had some pale mucosa, otherwise clear. She had tend erness along the left maxillary and left preauricular areas, and some mild tempo romandibular joint tenderness. Throat was clear. Neck was supple. Lungs: Clear t o auscultation. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and diffusely tender to a mild degree. Bowel sounds were active. A: 2. 3. 4. 1. Depression. Recurrent sinus pain. Constipation. Esophagitis.

P: 1. She has been off Zoloft for a while, so we will have her resume that. Ther e is no record in the chart of her ever having an adverse reaction to it. 2. Bec onase AQ 2 puffs b.i.d. 3. For her constipation, I recommended using Metamucil or some other type of sim ilar fiber, and increasing her fluid intake. She is going to make an appointment with Dr. Suess at his next opening, so that he can follow up on how she is doin g with these changes. If she continues to have the sinus pain, we may need to re fer her to an otolaryngologist. Return to top PATIENT CARE PLAN LETTER TO HEMATOLOGIST RE: Prince Charming Dear Dr. Doolittle:

I am sending Prince Charming to you in regards to some leukopenia and thrombocyt openia. He was a previous patient of The Wicked Witch and evidently had some low platelets and white counts in the past. In February, he had a white count of 41 00 with essentially a normal differential. His platelet count was 130,000. We repeated his complete blood count recently. He continues to have no anemia, b ut his white count is now 2800 and platelet count is 109,000. Antinuclear antibo dy was negative. His blood chemistry profile did show a mildly low globulin at 1 .7. Uric acid was slightly elevated at 8.7. Bilirubin was at 2. His retic count was 3 with an absolute reticulocyte count of 139.5, which is about double normal . I have included the laboratory studies for you to review. His vitamin B12 level was normal at 282. He is somewhat reluctant to see a hematologist. I told him th at you may recommend a bone marrow exam. At this point, he is feeling well and d oes not understand why he would nee to see another physician. I appreciate your evaluation. Sincerely, Dr. Suess Return to top HISTORY AND PHYSICAL (Hospital) History of Present Illness: This is a 43-year-old black man with no apparent pas t medical history who presented to the emergency room with the chief complaint o f weakness, malaise and dyspnea on exertion for approximately one month. The pat ient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia. Past Medical History: Essentia lly unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a r ecent PPD which was negative in August 1994. Medications: None. Allergies: No known drug allergies. Social History: He occasionally drinks and is a nonsmoker. The patient participa ted in homosexual activity in Haiti during 1982 which he described as "very acti ve." Denies intravenous drug use. The patient is currently employed. Family History: Unremarkable. Physical Examination: General: This is a thin, black cachectic man speaking in full sentences with oxy gen. Vital Signs: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30. HEENT: Funduscopic examination normal. He has oral thrush. Lymph: He has marked adenopathy including right bilateral epitrochlear and poste rior cervical nodes. Neck: No goiter, no jugular venous distention. Chest: Bilateral basilar crackles, and egophony at the right and left middle lun g fields. Heart: Regular rate and rhythm, no murmur, rub or gallop. Abdomen: Soft and nontender. Genitourinary: Normal. Rectal: Unremarkable. Skin: The patient has multiple, subcutaneous mobile nodules on the chest wall th

at are nontender. He has very pale palms. Laboratory and X-Ray Data: Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. He moglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1 , AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4 , direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room a ir. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alv eolar and interstitial infiltrates. Impression: 1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carini i pneumonia and tuberculosis. 2. Thrush. 3. Elevated unconjugated bilirubins. 4. Hepatitis. 5. Elevated globulin fraction. 6. Renal insufficiency. 7. Subcutaneous nodules. 8. Risky sexual behavior in 1982 in Haiti. Plan: 1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis. 2. Begin intravenous Bactrim and erythromycin. 3. Begin prednisone. 4. Oxygen. 5. Nystatin swish and swallow. 6. Dermatologic biopsy of lesions. 7. Check HIV and RPR. 8. Administer Pneumovax, tetanus shot and Heptavax if indicated. Return to top DISCHARGE SUMMARY DIAGNOSES: 1. Cerebrovascular accident. 2. Schizophrenia. 3. Recurrent transient ischemic attacks. PROCEDURES: 1. Echocardiogram. 2. Holter monitor. HISTORY OF PRESENT ILLNESS: This is a 59-year-old, right-handed woman with a history of hypertension, schizo phrenia, and a fallopian ovarian tumor resecte surgically and with radiotherapy treatment, who presented to the emergency room with a four-hour history of diffi culty talking, and numbness and weakness on the right side. She was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. Her numbness was associated with weakness as well a s difficulty speaking, with no associated headache, chest pain, fever, chills, d ouble vision difficulty swallowing or palpitations. She reported having a simila r incident about one month prior to admission when she was seen in the emergency room, but at that time, her symptoms resolve while in the emergency room. CT sc an at that time showed bilateral basal ganglion infarcts. Carotid duplex then sh owed minimal plaque, rig ht greater than left, with no hemodynamic stenosis. At that time, she was sent home on aspirin 1 q.d. which she has been taking except for the day prior to admission when she missed her dose. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 37.1, blood pressure of 164/100 in both arms. HEENT: Clear. NECK: Mild right bruit.

HEART: Regular rate and rhythm with no murmurs. LUNGS: Clear. ABDOMEN: Obese with a surgical scar. Bowel sounds were present. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: She was alert and oriented times three. She had difficulty with spee ch, mostly lingual sounds. No aphasic symptoms. Normal flow, normal rate and nor mal content. No breathlessness noted. Cranial nerves showed right fundi with sha rp discs, pupils reactive 3 to 2 bilaterally, full extraocular movements and ful l visual fields. Corneal reflexes were present bilaterally. Decreased V1 through V3 pinprick on the face. Masticatory muscles were normal. Face was symmetric. E ye closure, puffed cheeks and smile were symmetric. Uvula and tongue were midlin e. Her gag was present bilaterally, left greater than right. Motor examination s howed increased tone in the left arm. Strength was 4/4 in the right upper and lo wer extremities and 5/5 in the left upper and lower extremities. Reflexes were 2 + throughout with downgoing toes. Sensory examination showed decreased pinprick on the right side. There was decreased vibration bilaterally in upper and lower extremities. Normal stereognosis and graphesthesia. Gait: She was able to bear w eight on the left with some difficulty. LABORATORY DATA: Unremarkable. Head CT scan at the time of admission showed bila teral lacunae of the anterior internal capsule with basal ganglion involvement; no change from prior CT scan. Electrocardiogram showed normal sinus rhythm at 81 with Q-waves in leads I and aVL, and small Q-waves in V1 and V6. HOSPITAL COURSE: The patient was admitted to the neurology service with concern for an embolic versus ischemic event in the face of aspirin therapy. As an inpat ient, she had an echocardiogram which was reported to show mild, concentric, lef t ventricular hypertrophy with normal left ventricular function, no segmental wa ll abnormalities, no mitral regurgitation, no aortic regurgitation and no tricus pid regurgitation. No evidence of coral thrombus. Carotids were not repeated, si nce she had a carotid study one mont prior to admission that showed an occlusion of her carotids. RPR was nonreactive. Blood pressure remained under control dur ing hospitalization. Her psychiatric symptoms were stable during this time. She was seen by physical therapy and occupational therap who helped her with ambulat ion, and by discharge she was making good progress, ambulating and using her arm s, although she remained with weakness on the right more marked than the left. S he was discharged in good health. DISCHARGE MEDICATIONS: 1. Nortriptyline 25 mg p.o. q.h.s. 2. Benadryl 50 mg p.o. q.h.s. 3. Navane 5 mg p.o. q.h.s. 4. Aspirin 2 p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. Diet: Low-cholesterol, low-fat diet. 2. Activity: As tolerated. FOLLOW-UP CARE: 1. Followup with physical therapy and occupational therapy. 2. Return to the neurology clinic about one month after discharge.