Medical Transcription

Physical Exam

Physical Exam Sample
General:  cachectic (emaciated, malnourished) 
cachexia:  also  ca*chexy  n, pl  -chex*ias  also  -chex*ies  :  general physical wasting and malnutrition usu. associated with chronic disease .

EXAM:  She is afebrile, with a pulse of 78 per minute and regular.  Blood pressure is 148/79.  Weight:  148 lbs.

NEUROLOGIC EXAMINATION:  Patient is conscious, alert, oriented time, place, and person.  Memory for delayed recall is normal.  There is no apraxia or agnosia.  Information base is normal.  Examination of the cranial nerves reveal normal fundi and visual fields.  Pupils are normal in size, equally reacting.  Extraocular movements are full.  Cranial nerves VII through XII are normal.  Motor system examination reveals normal tone and power in all four extremities.  Reflexes are 2+ and symmetric bilaterally.  Both plantars are downgoing. 

There is no sensory loss to touch, pinprick, position or vibration.

There are no cerebellar signs and gait is unremarkable.  Carotids are equal without any bruits.

Medical Transcription Terms Home Page