Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the chest.

• The trachea is midline. The chest is normal in appearance. Palpation is normal. The chest is clear to percussion and auscultation.

• The trachea is midline. A mild pectus excavatum is present. There is increased tactile fremitus at the left posterior chest, up one third from the base. This area is also dull to percussion. Bronchial breath sounds and crackles are present in the area of dullness. Bronchophony and whispered pectoriloquy are also present in this area.

• The trachea is deviated to the left. The chest structure is within normal limits. There is decreased tactile fremitus on the right chest posteriorly, up three fourths from the base. The percussion note is dull in the area of decreased fremitus. There are no breath sounds heard in this area. An area of egophony is present above the area of dullness.

• The trachea is midline. Tactile fremitus is normal, as is percussion. Auscultation reveals normal breath sounds with bilateral basilar crackles.

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