The Written Physical Examination

After the examination has been completed, the examiner must be able to record objectively all the findings of inspection, palpation, percussion, and auscultation. Be precise in stating locations of abnormalities. Small drawings may be useful to describe a shape or location better. When describing the size of a finding, state the size in millimeters or centimeters rather than comparing it with a fruit or nut, for example, because these can vary greatly in size. It is best not to use most abbreviations because they may mean different things to different readers. However, the abbreviations used in the following examples are standard and may be used. Finally, do not make diagnostic statements in the write-up;save them for the summary at the end. For example, it is better to state that ''a grade III/VI holosystolic murmur at the apex with radiation to the axilla'' is present rather than ''a murmur of mitral insufficiency.''

Patient: John Henry*

General appearance: The patient is a 65-year-old white man who is lying in bed on two pillows and is in no acute distress. He is well developed and thin and appears slightly older than his stated age. The patient is well groomed, alert, and cooperative.

Vital signs: Blood pressure (BP), 185/65/55 right arm (lying), 180/60/50 left arm (lying), 175/65/50 left arm (sitting);heart rate, 90 and regular;respirations, 16.

Skin: Pink, with small hyperkeratotic papules over the face; nail beds slightly dusky; hair thin on head; hair absent on lower portion of lower extremities; normal male escutcheon (distribution of pubic hair).

Head: Normocephalic without evidence of trauma; no tenderness present.

Eyes: Visual acuity with glasses using near card: right eye (OD), 20/60, left eye (OS) 20/40; visual fields full bilaterally;extraocular movements (EOMs) intact;PERRLA [pupils are equal, round, and reactive to light and to accommodation] xanthelasma present bilaterally, L > R; eyebrows normal;bilateral arcus senilis present;conjunctivae without injection;opacities present in both lenses, R > L;left disc sharp with normal cup-disc ratio;normal arteriovenous (AV) ratio OS; no AV nicking present OS; there is a flame-shaped hemorrhage at the 6 o'clock position OS; several cotton-wool spots are also present at the 1 and 5 o'clock positions OS; right fundus not well visualized as a result of lenticular opacity.

Ears: Pinnae in normal position; no tenderness present; small amount of cerumen in left external canal;canals without injection or discharge;Rinne test, BC > AC right ear, AC > BC left ear; Weber test, lateralization to the right ear; both tympanic membranes are gray without injection;normal landmarks seen bilaterally.

Nose: Nose straight without masses; patent bilaterally; mucosa pink with a clear discharge present; inferior turbinate on the right slightly edematous.

Sinuses: No tenderness detected over frontal and maxillary sinuses.

Throat: Lips slightly cyanotic without lesions; patient wears an upper denture; buccal mucosa pink without injection;all lower teeth are present and are in fair condition;no obvious caries; gingivae normal; tongue midline without fasciculations; no lesions seen or palpated on tongue;mild injection of posterior pharynx with yellowish-white discharge present on posterior pharynx and tonsils; tonsils minimally enlarged; uvula elevates in midline; gag reflex intact.

Neck: Supple with full range of motion; trachea midline; small (1- to 2-cm) lymph nodes are present in superficial cervical and tonsillar node chains; thyroid borders palpable; no thyroid nodules or enlargement noted; no abnormal neck vein distention present; neck veins flat while patient is sitting upright.

Chest: Anteroposterior (AP) diameter increased; symmetric excursion bilaterally; tactile fremitus normal bilaterally; chest resonant bilaterally; vesicular breath sounds bilaterally; coarse breath sounds with occasional crackles present at the bases.

Breasts: Mild gynecomastia, L > R; no masses or discharge present.

Heart: Point of maximum impulse, sixth intercostal space (PMI 6ICS) 2 cm lateral to mid-clavicular line (MCL); normal physiologic splitting present; no heaves or thrills are present; S1 and S2 distant; a grade II/VI high-pitched holodiastolic murmur is heard at the 2ICS at the right upper sternal border; a grade I/VI medium-pitched systolic crescendo-decrescendo murmur is heard in the aortic area; the systolic murmur is midpeaking (Fig. 22-1).

Vascular: A carotid bruit is present on the right; no bruits are heard over the left carotid, renal, femoral, or abdominal arteries; lower extremities are slightly cool in comparison with upper extremities;1+ pretibial edema is present on the right lower extremity;2+ pretibial edema is present on the left; mild venous varicosities are present from midthigh to calf bilaterally; no ulceration or stasis changes are present; no calf tenderness is present.

Left Lower Abdominal Tenderness

Abdomen: The abdomen is scaphoid;a right lower quadrant (RLQ) appendectomy scar and a left lower quadrant (LLQ) herniorrhaphy scar are present;both scars are well healed; a 3 x 3 cm mass is seen in the RLQ after coughing or straining;no guarding, rigidity, or tenderness is present; no visible pulsations are present; bowel sounds are present; percussion note is tympanitic throughout the abdomen except over the suprapubic region, where the percussion note is dull;liver span is 10 cm from top to bottom in the MCL;spleen percussed in left upper quadrant but not palpated;kidneys not felt;no costovertebral angle tenderness (CVAT) present; an easily reducible right indirect inguinal hernia is felt at the external ring.

Rectal: Anal sphincter normal; no hemorrhoids present; nontender prostate enlarged symmetrically; prostate firm without nodules felt; no luminal masses felt in rectum; stool negative for blood.

Genitalia: Circumcised man with normal genitalia; penis without induration; left hemi-scrotum 4 to 5 cm below the right;palpation of left hemiscrotum reveals dilatation of the pampiniform plexus;soft testes 2 x 3 x 1 cm bilaterally.

Lymphatic: Nodes in anterior triangle chains already noted; two firm, 1- to 2-cm, rubbery, freely mobile nodes in left femoral area; no epitrochlear, axillary, or supraclavicular nodes felt.

Musculoskeletal: Distal interphalangeal joint enlargement on both hands, causing pain on making a fist, L > R;no tenderness or erythema present;proximal joints normal;neck, arms, hips, knees, and ankles with full range of active and passive motion; muscles appear symmetric;mild kyphosis present.

Neurologic: Oriented to person, place, and time; cranial nerves I to XII intact; gross sensory and motor strength intact; cerebellar function normal; plantar reflexes down; gait normal;deep tendon reflexes as shown in Table 22-1.

Summary: Mr. Henry is a 65-year-old man in no acute distress. Physical examination reveals systolic hypertension, retinal changes suggestive of sustained hypertension, a mild cataract in his right eye, a conductive hearing loss in his right ear, tonsillopharyngitis, and gynecomastia. Cardiac examination reveals aortic insufficiency. Peripheral vascular examination reveals possible atherosclerotic disease of the right carotid artery and mild venous disease of the lower extremities. The patient has a right, easily reducible inguinal hernia. A left-sided varicocele is present. Mild osteoarthritis of the hands is also present.

Table 22-1

Deep Tendon Reflexes of Patient John Henry

Side

Biceps

Triceps

Knee

Achilles

Right

1 +

0

2+

1+

Left

2+

1 +

3+

2+

Patient: Mary Jones*

General appearance: The patient is a 51-year-old African-American woman who is sitting up in bed in mild respiratory distress. She is obese and appears to be her stated age. She is well groomed and alert, but she constantly complains about her shortness of breath.

Vital signs: BP, 130/80/75 right arm (lying), 125/75/70 left arm (lying), 120/75/70 (sitting); heart rate, 100 and regular;respirations, 20.

Skin: Upper extremities slightly dusky in comparison with lower extremities;good tissue turgor;patient is wearing a wig to cover her marked total baldness;normal female escutcheon.

Head: Normocephalic without evidence of trauma;face appears edematous;no tenderness noted.

Eyes: Visual acuity using near card: OD, 20/40, OS, 20/30;visual fields full bilaterally;EOMs intact;PERRLA;eyebrows thin bilaterally;conjunctivae red bilaterally with injection present; lenses clear;both discs appear sharp with some nasal blurring;the cup-disc ratio is 1:3 bilaterally, and the cups are symmetric; the retinal veins appear dilated bilaterally.

Ears: Pinnae in normal position; no mastoid or external canal tenderness; canals without injection or discharge;Rinne test, AC > BC bilaterally;Weber test, no lateralization;both tympanic membranes clearly visualized;normal landmarks seen bilaterally.

Nose: Straight without deviation; mucosa reddish-pink; inferior turbinates within normal limits.

Sinuses: No tenderness detected.

Throat: Lips cyanotic; all teeth present except for all third molars, which have been extracted; occlusion normal; no caries seen; gingivae normal; tongue midline with markedly dilated tortuous veins on undersurface; no fasciculations of tongue noted; posterior pharynx appears within normal limits; uvula midline and elevates normally; gag reflex intact.

Neck: Full with normal range of motion;trachea midline;neck veins distended to angle of jaw while sitting upright; no adenopathy of neck noted.

Chest: AP diameter normal; symmetric excursion bilaterally; increased tactile fremitus at right base posteriorly corresponds to area of bronchial breath sounds; percussion note in this area is dull, all other chest areas are resonant; bronchophony and egophony present in area of bronchial breath sounds; crackles and wheezes present in area at right posterior base.

Breasts: Left mastectomy scar; right breast without masses, dimpling, or discharge.

Heart: PMI 5ICS MCL;normal physiologic splitting present;no heaves or thrills present; S1 and S2 within normal limits; no murmurs, gallops, or rubs present.

Vascular: There are no bruits present over the carotid, renal, femoral, or abdominal arteries; the extremities are without clubbing or edema.

Abdomen: The abdomen is obese without guarding, rigidity, or tenderness; no visible pulsations are present; bowel sounds are normal; percussion note is tympanitic throughout the abdomen; liver span is 15 cm in the MCL; spleen not percussed or palpated; kidneys not palpated; no CVAT present.

Rectal: Refused.

Pelvic: Deferred until patient more stable.

Lymphatic: No adenopathy felt in the neck chains or in the epitrochlear, axillary, supra-clavicular, or femoral regions.

Musculoskeletal: Marked edema of both upper extremities, L > R; neck, arms, knees, and ankles with full range of active and passive motion; muscles appear symmetric except for upper extremities.

Neurologic: Oriented to person, place, and time;cranial nerves I to XII intact;gross sensory and motor strength intact; cerebellar function normal; plantar reflex down bilaterally; deep tendon reflexes as shown in Table 22-2.

Table 22-2 Deep Tendon Reflexes of Patient Mary Jones

Side Biceps

Triceps

Knee

Achilles

Right 2+

2+

2+

1+

Left 2+

1 +

2+

2+

Summary: Ms. Jones is a 51-year-old African-American woman, status post left mastectomy, in respiratory distress. She is cyanotic and has evidence of vascular engorgement of the upper half of her body. Her trachea is fixed to the mediastinum. Chest examination reveals evidence of consolidation of the right lower lobe of her lung.

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