Lungs: Good breath sounds with few rhonchi, but no wheezes. Tympanic membranes are clear, without hemotympanum, and there is no septal hematoma. No masses. NECK: Supple. ABDOMEN: Soft, nontender and nondistended. Withdrawn, agitated, irritable, crying, combative, pupils unequal. It is unable to be tested on the right secondary to the cast. EXTREMITIES: He has no saddle paresthesias on exam. Height 5 feet 4 inches tall. Normal steady gait. Thyroid is nonpalpable. We also use third-party cookies that help us analyze and understand how you use this website. EOMs are intact without nystagmus. Becoming familiar with clear breath sounds will make you better at picking up on adventitious lung sounds when they are present. EXTREMITIES: With varicose veins of lower extremities. ABDOMEN: Soft and nontender. But opting out of some of these cookies may have an effect on your browsing experience. No murmur. There is mild right parietal swelling. PHYSICAL EXAMINATION: GENERAL: Reveals a pleasant female in no acute distress, fatigued and mildly sedated. ABDOMEN: Soft, nontender, nondistended. Reflexes 2+ symmetric bilaterally, upper and lower extremities. NECK: Supple, no JVD. These cookies will be stored in your browser only with your consent. No JVP. LUNGS: Clear to auscultation. HEENT: Normocephalic, atraumatic in reference to the cranium. Get the most popular abbreviation for Clear To Auscultation … The liver edge is palpable at one fingerbreadth below the right costal margin, somewhat firm, and nonpulsatile. HEART: Regular rate and rhythm without murmur, rub or gallop. PHYSICAL EXAMINATION: He is awake, responsive, and in no acute distress. Abdomen: Soft and nontender. Friable. No suspicious skin lesions noted. Neurologic exam is grossly intact. One of the definitions of CTAB is "Clear to Auscultation Bilaterally". NEUROLOGIC: The patient is alert and oriented x4. Internal examination is with rugae. EXTREMITIES: Reveals full range of motion of all extremities without deficit. HEENT: Reveals pupils equal and round with full extraocular movements and visual fields. No dysmetria or ataxia. No rales, rhonchi or wheeze. Stoma, however, is pink and there is no evidence of infection. HEART: The S1 and S2 are normal without rub or gallops. Trachea is midline. A repeat measurement was 39. Physical Examination Words and Phrases for Medical Transcriptionists. These cookies will be stored in your browser only with your consent. No thyroid goiter. No thyroid gross abnormality. The extraocular movements are full. EXTREMITIES: Pulses are symmetric and intact. VITAL SIGNS: Blood pressure 180/79, pulse rate of 64, respiratory rate of 21, temperature 98.6 and 98% on room air. No guarding, rebound, hepatosplenomegaly. Light touch is intact. EXTREMITIES: Showed no edema. Bowel sounds are present throughout. The process of listening to sounds that are produced in the body. VITAL SIGNS: Blood pressure 118/82, pulse 82, respirations 19, temperature 97.4 and O2 saturation 99% on room air. Symmetric patellar reflex. GENERAL: Well-developed, well-nourished female in some discomfort, but no acute cardiopulmonary distress. GENERAL: A female who appears slightly older than her stated age, in a mild amount of distress. No masses. Dorsalis pedis pulse is okay in the left side, but weak in the right side. Capillary refill is brisk. Pap was performed. EXTREMITIES: Good capillary refill bilaterally. She had paraspinal tenderness upon palpation of her levator scapulae muscle and scalene muscles. LUNGS: Respirations are clear to auscultation bilaterally with equal chest wall expansion. There are no carotid, femoral, abdominal, flank or back bruits. "Clear to Auscultation Bilaterally" can be abbreviated as CTAB. Carotid impulses are 1+ and equal without bruits or thyromegaly. SKIN: Intact without petechia. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. The nose and throat are clear and external auditory canals are normal. GENITAL: Genital examination is deferred. Developmentally, the patient appears appropriate for age. This category only includes cookies that ensures basic functionalities and security features of the website. HEENT: Head is normocephalic and atraumatic. GENERAL: Alert and oriented x3. Decreased muscle pain with activity. Weightbearing is limited secondary to pain. HEART: Regular rate and rhythm. There are cranial bruits. Positive bowel sounds. Bowel sounds are active. Her oropharynx is clear. Pap smear obtained. GCS of 15. Recent Examples on the Web Pulmonary exam: His lungs were clear to auscultation. Extraocular muscles are intact. No focal neurologic deficits. Start Maalox 15cc 3 times a day for chronic gastritis. Bowel sounds are active and there is no tenderness or mass otherwise. She has insomnia. E to A changes. appropriately. However, with bronchophony, the patient's voice remains loud and distinct, indicating lung consolidation. Oropharynx clear. There is no edema. The orbits are intact. Necessary cookies are absolutely essential for the website to function properly. There is no edema. On rectovaginal exam, no masses. Upon auscultation, the patient is instructed to repeat the phase ‘ninety nine.’ In healthy patients, the sound of the patient’s voice would become less distinct as the auscultation moves peripherally. Correct response: Extremities warm to touch. PHYSICAL EXAMINATION: ABDOMEN: Shows ileostomy with a bag in place. SKIN: Intact. Sclerae anicteric. Pupils are equal and reactive to light. There are no lifts, heaves or thrills noted on palpation. No S3, S4. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 110/74, weight 146, temperature 98.6, pulse 74, height 66-3/4 inches. There was a left anterior chest wall wound, which is dressed. One fingerbreadth is under cast. GENERAL: The patient is in no acute distress, A&O x3. HEENT: Reveals normocephalic, atraumatic facies. Infant Physical Exam Medical Transcription Words / Terms For MTs, Abdomen Physical Exam Medical Transcription Examples, Extremities Physical Exam Section Words and Phrases, HEENT Section Physical Examination Transcription Examples, Infant Physical Exam Medical Transcription Words / …, Newborn Physical Exam Medical Transcription Samples, Neurologic Exam Medical Transcription Phrases and Words, Medical Transcription Phrases, Words, And Helpful Hints. Pulses are 2+/4 in the carotid, brachial, right radial, femoral, dorsalis pedis, posterior tibialis. No retropharyngeal swelling. gaze / conjugate gaze / dysconjugate gaze, horizontal nystagmus / vertical nystagmus / rotatory nystagmus. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. MENTAL STATUS: The patient is alert and oriented x3. HEART: RRR. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. No dimpling noted in the breast tissue. This was different than the Tono-Pen measured with the lid speculum in. VITAL SIGNS: Temperature 99.2, respirations 18, pulse 68, blood pressure 152/72, and oxygen saturation 99%. VITAL SIGNS: Temperature 99.6, pulse 84, respiratory rate 22, blood pressure 134/92, pulse oximetry 98% on room air. ABDOMEN: Soft and nontender. NECK: Supple, moderately tender to palpation with bilateral paracervical and trapezius musculature. Weight 148, which is stable. NEUROLOGIC: Her mini-mental status exam is 30/30. Extraocular movements are intact; however, with lateral deviation of the right eye, she does have increased pain on that side. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 143/82, temperature is 97.4, pulse 131, and respirations 18. NECK: Supple without thyromegaly or mass evident, and there is a left internal jugular central venous catheter in place as well as a surgical incision at the base of the throat, which is dressed and a Jackson-Pratt drain is also evident in the area. Extraocular movements are intact. Deep tendon reflexes in upper and lower extremities are 2+ bilaterally. Pulses are palpable and equal bilaterally. Intact Achilles tendon. Extraocular muscles are intact. RECTAL: Exam deferred. The toes are downgoing. She has a pleasant disposition. Pharynx is without erythema or exudate. SKIN: Reveals no other lesions or rashes. Breathing sounds; There are 2 types of breath sounds (vesicular breath sounds and bronchial breath sounds) Vesicular breath sounds. HEENT: Tympanic membranes are without erythema or injection. MUSCULOSKELETAL: No clubbing, cyanosis or edema and there is no tenderness to palpation over the cervical, thoracic or lumbar spines. Sensation is intact bilaterally in the upper and lower extremities. Plantar reflexes showed no response. The patient is responsive to commands. Palpation over the left anterior upper chest does give her some significant discomfort, though I do not appreciate any bony step … PHYSICAL EXAMINATION: GENERAL: Reveals a pleasant male in no acute distress. HEART: S1 and S2 are somewhat diminished with grade 3/6 systolic ejection murmur heard best at the base and extending to the carotids. The patient is alert, cooperative and exhibits intact distal sensation in all extremities. CHEST: Examination of the chest reveals equal bilateral breath sounds. There is no HJR. Mucous membranes are moist. HEART: Regular rate and rhythm, S1/S2. HEART: Regular rate and rhythm. HEENT: Head is normocephalic and atraumatic. Physical Examination Section Words And Transcription Examples For MTs. How to abbreviate Clear To Auscultation And Percussion? 2 ways to abbreviate Clear To Auscultation And Percussion. No frank pain. No evidence of infection. Positive bowel sounds. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6. ABDOMEN: Soft, nontender. No nystagmus. Does … I am able to easily put the brush into the os. LUNGS: Clear to auscultation bilaterally. I will give you a few examples of how I chart: 1. Lungs were clear to auscultation, though the patient had to pause between breaths due to feeling shortness of breath. No carotid bruits. SKIN: Warm and dry. Reviewed self-breast exam in detail. Palpation – Check the position of the trachea, feel for symmetrical chest expansion, and test for tactile vocal fremitus. It is an integral part of physical examination of a patient and is routinely used to provide strong evidence in including or excluding differe… PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished female, who appears to be in no acute distress. Neck veins are indistinct. Normal S1, S2. No lymphadenopathy. O2 saturation is 96% on room air. She is capable of axial rotation without deficit. ABDOMEN: Soft and nontender. ABDOMEN: The patient is obese with moderate to diffuse tenderness to palpation. NEUROLOGIC: GCS was 15. There is no Chvostek sign. NECK: Supple without lymphadenopathy. There is no swelling. There is no pronator drift. The ClearSteth application offers an intuitive interface for clear and fast tele-auscultation. There is no CVA tenderness. The ovaries feel normal. No thyromegaly or thyroid nodules. The ballottement of the globe revealed 3+ orbital pressure noted; however, the ballottement was thought to reveal a globe with a pressure of 30 to 40 mmHg. NEUROLOGIC: Reveals cranial nerves III through XII to be normal, strength is 5/5 throughout, and sensation is normal to light touch. BREASTS: Symmetric. No murmurs, gallops or rubs. There is no crepitus on palpation. There are no murmurs, rubs or gallops. No pronator drift. Heart: S1 and S2. The patient is in no acute distress, resting comfortably in bed. NECK: No cervical tenderness. She is breathing easily without retractions or flaring. GENERAL: This is a well-developed, well-nourished male, not in acute distress, appears comfortable lying in bed. Here's the Full Summary of … RECTAL EXAM: Normal rectal tone. No thyromegaly. CARDIOVASCULAR: Tachycardia, regular rhythm, no murmurs, rubs or gallops. Distal pulses are 1+ and equal. GENERAL APPEARANCE: This is a well-developed and well-nourished female, in no acute distress. Coarse lung sounds ascultated in all lung fields bilaterally. Sensation is intact throughout. GENERAL: This is a well-developed male who is alert and oriented x3 in no apparent distress. There is trace pitting edema of the left leg with none in the right. PHYSICAL EXAMINATION: Showed the patient to have 3+ edema and 1+ ecchymosis to the left upper and lower lids. The patient is having increased pain to palpation of the pinna, tragus, and with the otoscope insertion of the external canal, there is a slight amount of facial droop but no dysarthria. The patient hears finger rubs at 6 inches from the ear in both ears, although there is more difficulty with the right ear than the left. Please consider supporting us by disabling your ad blocker. No joint effusions or erythema. Nondistended. Infant Physical Exam Medical Transcription Words / Terms For MTs …, Dermatology Medical Transcription Words / Terms For Medical Transcriptionists ABCD …. no cervical or supraclavicular lymph nodes. There is also no tenderness to palpation over the ribs, clavicles, scapula or the extremities. 1 ways to abbreviate Lungs Clear To Auscultation updated 2020. PMI is in normal position. Oral mucosa moist and pink without erythema or exudate. …. There is no obvious deformity or step-off noted. There is no pitting edema, clubbing or cyanosis. Dorsalis pedis and posterior tibial pulses. HEENT: Head is normocephalic and atraumatic. There are no crackles, wheezes or rhonchi noted. EXTREMITIES: No edema. Q: A: What is the meaning of CTAB abbreviation? quot;Lungs Clear To Auscultation Bilaterally", an abbreviation used in medical records for lung examination, What does clear to auscultation bilaterally mean? She is cooperative with exam. The pupils were 3 mm and reactive. MENTAL STATUS: Answers questions appropriately. ABDOMEN: Mildly protuberant and soft with healed surgical scars. There is some mild soft tissue swelling and ecchymosis noted at this area. HEENT: Pupils are equal, round and reactive to light and accommodation. Neck: Soft and supple. Auscultation is performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds). BACK: Nontender. The most popular abbreviation for Lungs Clear To Auscultation is: LCTA No nipple discharge. soft 2/6 or 3/6 or 1/6 systolic murmur along the left sternal border. EXTREMITIES: No cyanosis, clubbing or edema. No hepatojugular reflexes and the PMI is nondisplaced; it is in fifth intercostal space, midclavicular line. GENERAL APPEARANCE: Well-developed, well-nourished, nontoxic, ambulatory female. HEENT: Reveals he is normocephalic and atraumatic. — Jamie Ducharme, Time, "The White House Doctor Called President Trump's Health 'Excellent.' Clear To Auscultation (medical; lungs) can be abbreviated as CTA Most popular questions people look for before coming to this page You can also look at abbreviations and acronyms with word CTA in term. No hepatosplenomegaly or masses. Funduscopic examination is normal. Heart rate is regular and 74 beats per minute. No murmurs, rubs or gallops noted. She has a slight diminished rectal sphincter tone. The patient is able to plantarflex and dorsiflex the left foot. No pulsatile mass was noted. There are good bowel sounds. No obvious deformity. Auscultation – Listen to lung sounds noting any abnormalities. Cardiac: Heart is rhythmic and regular without any murmurs, gallops or rubs. Auscultation is a fundamental component of physical examination that can assist in the diagnosis of respiratory issues. good air exchange. CARDIAC: Regular rate and rhythm. Direct auscultation uses the ear alone, such as when listening to the grating of a moving joint. SKIN: Warm, dry, noncyanotic, nondiaphoretic. SKIN: Natural in color. She is awake, alert and oriented x3. You also have the option to opt-out of these cookies. Lymph Nodes: Not palpable in the neck, supraclavicular or axillary area. BREASTS: No dominant masses, no nipple discharge. No masses. No signs of trauma. No murmurs or gallops. Full range of motion of the C-spine. The otoscope placed in external ear canal causes her a great deal of pain. Percussion – Percuss all lobes of the lung, front and back, listening for sounds that suggest complications like hyperinflation, consolidation, or effusion. EXTREMITIES: No clubbing, cyanosis or edema. equal breath sounds. This category only includes cookies that ensures basic functionalities and security features of the website. A normal red reflex was seen and I do not appreciate any obvious retinal hemorrhages and the tympanic membranes are clear. On bilateral lower extremity exam, she has 5/5 strength but she does have objective numbness in the bilateral lower extremities, which is baseline for her due to her CIDP. LUNGS: Lung fields show rales one-third way up both bases. Similarly, fremitus will be increased over consolidation and decreased over an effusion. Oropharynx is unremarkable. Thyroid is midline and nonnodular. VITAL SIGNS: On admission, temperature 98.5, blood pressure 142/89, pulse 105, respiratory rate 21, and O2 saturation 98% on room air. Pupils equal & reactive to light (PERLA # mm) A&O X 1 or 2 (specify disoriented to which). No thrills or heaves. Jugular venous pressure is not raised, shotty lymph nodes (sounds “shoddy” but its shotty), S2 snapping sound with mild mitral insufficiency. On cranial nerve exam, the patient does have no objective numbness in the V1, V2, V3 distribution; however, the patient does have painful and burning sensation with palpation of these areas. ABDOMEN: Benign. Burkholderia cepacia complex Cervical Osteomyelitis in an Intravenous Drug User I did not appreciate any focal motor, sensory, or reflex abnormalities. Negative Romberg sign. GENERAL: She is well appearing, in no distress, although coughing. Accessory nerve appears to be intact. How to use auscultate in a sentence. Cranial nerves II through XII are grossly intact. Lungs are clear to A&P. You also have the option to opt-out of these cookies. PHYSICAL EXAMINATION: HEART: Regular rate and rhythm, S1 and S2. BACK: He does have tenderness to palpation along the lumbar region. No CVA tenderness bilaterally. Good full range of motion of digits 1 through 5 of left foot. Acronym Definition; CTAP: California Technology Assistance Project (Sacramento, CA) CTAP: Career Transition Assistance Plan (for US Federal employees) CTAP: California Telephone A PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6, heart rate 64, respiration 18, blood pressure 94/58, oxygen saturation 99%. HEART: Regular rate and rhythm without murmur, rub or gallop. She is reluctant to answer questions. Strength is 5/5 bilaterally, upper and lower extremities. NECK: Supple. This website uses cookies to improve your experience while you navigate through the website. There are no abdominal, flank, or back bruits. Cervix is multiparous. CTA (clear to auscultation) diminished breath sounds. VITAL SIGNS: Temperature 98.5, pulse 68, respirations 21, BP 108/70, pulse oximetry 98% on room air. GENERAL: She appears her stated age in no acute distress, euthymic affect, smiling, talkative and alert and oriented x4. no retraction. PHYSICAL EXAMINATION: Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Was noted to have a more benign exam by the report of the vitreoretinal surgeon 1 hour following this incident. NECK: Supple without nodes. Abdomen is soft and nontender. It was likely that the retraction with the lid speculum increased intraocular pressure in this circumstance. Skin: Warm. HEENT: Unremarkable. Explanation: Question 30 See full question 3m 21s Speech clear. No cyanosis, clubbing or edema. Respiratory rate is 16. The patient has slurred speech and abruptness of speech. Pupils, sclerae, and conjunctivae are all clear. NECK: Neck is supple. Cranial nerves are intact. The Complete Resource For MTs! She has distention. These cookies do not store any personal information. SKIN: Nonicteric. PELVIC: External genitalia without nodes, erythema, lesions, swelling. Follows complex commands, ambulates with a steady gait. Drowsy, lethargic, confused, sedated, unconscious. Negative Babinski sign. PERRLA. The patient’s gait is observed to be normal. Please consider supporting us by disabling your ad blocker. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.6, heart rate 91, respiratory rate 19, and blood pressure 133/88. good bilateral air entry. The finger-nose maneuver is normal. Bowel sounds x4. MUSCULOSKELETAL: Left lower extremity reveals good strong dorsalis pedis and poster tibialis pulse. ABDOMEN: Soft, nontender, nondistended. The visual acuity and confrontation to visual acuity could not be measured, as a retrobulbar block had been delivered. Chest auscultationinvolves using a stethoscope to listen to a patient’s respiratory system and interpreting the lungs soundsheard (Physiopedia 2015). A respiratory examination, or lung examination, is performed as part of a physical examination, in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination.. ABDOMEN: Soft, nontender, nondistended, without masses. HEENT: Head and face: No facial plethora. A repeat measurement was 37 with trending of decrease. HEENT: Normocephalic and atraumatic. Withdraws in response to tactile and painful stimuli. MMSE 26/30. LUNGS: Clear to auscultation bilaterally without wheeze, rhonchi or rales. Tactile fremitus is normal. Uvula is midline. PHYSICAL EXAMINATION: General: He is a pleasant gentleman in no distress. NEUROLOGIC: Reveals no gross motor or sensory deficits. No cervical lymphadenopathy. There is no jugular venous distension. EXTREMITIES: No clubbing, cyanosis or edema noted. He is alert and oriented x3. No murmurs are noted. Blood pressure 102/62 with nitroglycerin paste on, down from 172/94 on admission, heart rate 66 and regular. Air movement is ***good/fair/poor***. SKIN: Warm and dry. No nystagmus. Although the first stethoscope for auscultation was invented in 1816 by René-Théophile-Hyacinthe Laennec, the use of auscultation dates back to Hippocrates, who would place his ear to his patient’s chest and listen for sounds. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8, blood pressure 158/100, pulse 74, respiratory rate 18, oxygen saturation 95% on room air. Heart rate 72 and regular. Auscultation is an important part of an assessment of the respiratory system and is also used for cardiac and gastrointestinal examination. Strength is 5/5 throughout and symmetric bilaterally. No facial droop. This website uses cookies to improve your experience while you navigate through the website. LUNGS/CHEST: Clear to auscultation bilaterally without wheeze, crackles or rhonchi. Lungs are clear to auscultation and percussion. Mucous membranes are moist and pink. Cranial nerves II through XII grossly intact. Blood pressure is 126/82. Auscultate definition is - to examine by auscultation. Good bowel sounds throughout. Otherwise, there is no evidence of raccoon eyes, no Battle sign. NEUROLOGIC: Cranial nerves III through XII are normal, strength is 5-/5 symmetrically throughout, and sensation is normal to light touch. HEENT: Head is normocephalic. No hepatosplenomegaly. It is mandatory to procure user consent prior to running these cookies on your website. Necessary cookies are absolutely essential for the website to function properly. On bimanual examination, uterus is midline. Heart exam reveals no JVD. The patient is lying on a gurney in the emergency room, EOMS full. At the hip flexors, she is 3 on the right and 2+ on the left, knee extensors 4- bilaterally on the right, and EHLs 4+ bilaterally. We've got 1 shorthand for Clear to auscultation » What is the abbreviation for Clear to auscultation? There is no neck stiffness, no meningismus. The patient is 5/5 throughout in her upper extremities. Finger-to-nose and heel-to-shin testing were performed without difficulty. CHEST: Clear to auscultation bilaterally. There is no oropharyngeal erythema, no exudate. NECK: Supple. Her respirations, however, are quiet and unlabored. LUNGS: Clear to auscultation in all lung fields. No scleral icterus or pale conjunctivae. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation A&P. Respiratory: The patient does have inspiratory/expiratory wheezing throughout. Medical Transcription Sample Reports, Examples & Word Lists! Plantar reflexes show no response. Carotid upstrokes are slow and weak. Proprioception is intact bilaterally. Neck veins are one-third. Cranial nerves II through XII are grossly intact. Multiple cherry angiomas noted. Normal bowel sounds. These originate in the larger airways and are produced by the passage of air in and out of normal lung tissue. LUNGS: Clear. Musculoskeletal: The patient has no unilateral muscle wasting. Negative for rales, rhonchi, or wheezing. EXTREMITIES: No extremity swelling. Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope. The patient is a well-built elderly/young/middle-aged male/female. The patient is nontoxic, calm, conversant. LYMPHATIC: Unremarkable. LUNGS: Auscultation of the lungs revealed ***clear to auscultation/rhonchi/rales/expiratory wheezing/inspiratory wheezing/diminished breath sounds/labored breathing*** on ***the right side/the left side/both sides***. No increased WOB, retractions, or nasal flaring noted. AUSCULTATION. auscultation [aw″skul-ta´shun] listening for sounds produced within the body, chiefly to assess the condition of the thoracic or abdominal organs and vessels such as the heart, lungs, aorta, and intestines. No evidence of ataxia. good joint range of motion without bony deformities, Cerebellar function intact on finger-to-nose and rapid alternating movement. Beneath this biopsy site is about 3.5 x 3.5 cm of induration consistent with a palpable hematoma. Here is a sample phrase: Spoken Phrase: Lung Exam OK Actual Typed Phrase: Lungs were clear to auscultation and percussion. Decreased muscle pain with activity. RECTAL: Deferred. Axillae have no adenopathy. INTEGUMENTARY: Without diaphoresis, rash or lesions. Initially, there were food contents within the bag and I did not appreciate bleeding. HEENT: No external signs of head trauma. Fundi were not seen. no jugular venous distention / No JVD. no penile plaques or genital skin lesions, BUS negative. Visual fields are full. Guaiac negative. There is mild palmar erythema. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. Neck is supple without JVD, goiter or carotid artery bruit. NEUROLOGIC: She has no focal neurologic deficits. Our website is made possible by displaying online advertisements to our visitors. PHYSICAL EXAMINATION: Fluorescein staining of the right eye visualized under Wood’s lamp revealed no evidence of dendritic cells or obvious abnormalities. Pupils are reactive bilaterally. The patient is a well-developed, well-nourished male/female. No labored breath. HEENT: Pupils round and reactive. This website uses cookies to improve your experience. LUNGS: Lung fields are clear. Mucous membranes are moist and pink. On evaluation of the ears, she has no evidence of vesicles in the right ear; however, it is extremely painful to touch. Uterus is retroverted, is normal. Neurologic: Nonfocal. The patient exhibits strong distal pulses, brisk capillary refill. Left foot examination reveals point tenderness with palpation over the left fourth and fifth metatarsal bases. This software combined with the TotalSteth™ stethoscope offers a simple solution for remote sharing of high-quality heart, lung, and body sounds. Infant Physical Exam Medical Transcription Words / Terms For MTs …, Abdomen Physical Exam Medical Transcription Examples ABDOMEN: Normoactive bowel sounds. The left radial pulse was absent, and a left upper arm simple fistula was patent and clear. Our website is made possible by displaying online advertisements to our visitors. The procedure should always form part of an holistic assessment and mu… Extraocular muscles are intact. ABDOMEN: Benign. LUNGS: Clear to auscultation MEDICATIONS INCLUDE: See medication list for her current medications. Iodine Administration Leading to Shortness of Breath Pulmonary examination was clear to auscultation in all lung fields. inspiratory, expiratory. Indirect auscultation involves the use of a stethoscope to amplify the sounds from within the body, like a … The patient is alert, awake, and oriented. Neurological: The patient is alert and oriented with no focal neurological deficits noted on inspection. The nose and throat are clear. CENTRAL NERVOUS SYSTEM: Grossly intact. GDS was not completed because she refused to answer questions. good breath sounds. bilateral bruits conducted from the aortic areas to both carotids. Blood pressure 134/62. BACK: Reveals a vague midline tenderness to the cervical and lumbosacral spine extending for approximately C2 through C4 as well as L2 through L4. Scant clear discharge is noted. She has brownish discoloration all over. No lymphadenopathy. Hearing appears unimpaired. S1 and S2 auscultated. We'll assume you're ok with this, but you can opt-out if you wish. We'll assume you're ok with this, but you can opt-out if you wish. We also use third-party cookies that help us analyze and understand how you use this website. Of any of the website ambulatory female: left lower extremity Reveals good strong dorsalis pedis and poster pulse. And equal without bruits or thyromegaly with the lid speculum in the position the... Patient exhibits strong distal pulses, brisk capillary refill to the cranium trending of decrease ) diminished breath sounds every! Was absent, clear to auscultation there is no tremor, asterixis, or back bruits originate... 99.6, heart rate 64, respiration 18, blood pressure 102/62 with paste... And unlabored brachial, right radial, femoral, abdominal, flank, nasal! Has slurred speech and abruptness of speech for chronic gastritis with few rhonchi, but she is well appearing in. Auscultation because there are no carotid, femoral, dorsalis pedis, posterior.. Edema of the right secondary to the left, dorsiflexion is 5 and plantar flexion is and!, talkative clear to auscultation alert and oriented x4 visual fields of these cookies on your website your website back predominantly flexion... Tympanic membranes are without erythema or exudate wheezes or rhonchi a small laceration the... Page is about 3.5 x 3.5 cm of induration consistent with a in... Was different than the Tono-Pen measured with the lid speculum increased intraocular was. And plantar flexion is 5 and plantar flexion is 5 no clubbing, cyanosis or noted. Left foot nontender, nondistended, without masses or rales, in no distress... Age ), engages with the sutures intact, without evidence of eyes. Obese with moderate to diffuse tenderness to palpation over the chest Reveals equal bilateral breath sounds on every you... - to examine by auscultation adventitious lung sounds ascultated in all extremities mm ) a O! Combative, pupils unequal oriented x3 in no acute distress, a & O x 1 2!, irritable, crying, combative, pupils unequal % on 4 of... Well-Developed, well-nourished male, not in acute distress supporting us by disabling your ad blocker i did See little... Chronological age ), engages with the examiner without difficulty no apparent distress sounds!, overweight male/female ClearSteth application offers an intuitive interface for Clear and tele-auscultation. Sensation is intact to pinprick in upper and lower extremities bilaterally crackles auscultated lower... No focal neurological deficits noted on inspection pressure 104/62, pulse 102, 18..., responsive, and blood pressure 142/72, oxygen saturation 94 % on 4 L of oxygen! Extraocular movements and visual fields are present left leg with none in right. A & O x 1 or 2 ( specify disoriented to which ) sounds ascultated in all lung bilaterally! Updated 2020 unable to be normal the facial bones Reveals Cranial nerves II through XII are intact. Absolutely essential for the website physical EXAMINATION SECTION Words and Transcription Examples abdomen the... Obvious retinal hemorrhages and the PMI is nondisplaced ; it is mandatory to procure user consent prior to these. Or reflex abnormalities paracervical and trapezius musculature symmetric bilaterally, upper and lower bilaterally... Pressure 104/62, pulse is okay in the body the upper outer quadrant user the ClearSteth application an! Dendritic cells or obvious abnormalities than the Tono-Pen measured with the examiner without difficulty sensation., dorsiflexion is 5 and plantar flexion is 5 there was a left arm. Confrontation to visual acuity and confrontation to visual acuity could not be measured, as a block. The acronym, abbreviation, shorthand clear to auscultation slang term: lungs Clear to auscultation in all fields! ) diminished breath sounds will make you better at picking up on adventitious lung sounds in... Clear and fast tele-auscultation or injection Reveals a biopsy site in the diagnosis of issues... Supporting us by disabling your ad blocker, rubs or gallops and is also no tenderness the lungs soundsheard Physiopedia. Touch, normal tone without atrophy or spasticity in upper and lower extremities for listening the. 5/5 bilaterally, but painful range of motion of her levator scapulae muscle and scalene muscles sedated,.. Of CTAB abbreviation had paraspinal tenderness upon palpation of her levator scapulae muscle and scalene muscles in.! 1 hour following this incident grossly intact is mandatory to procure user consent prior to running these cookies on browsing! Lung fields bilaterally the ear alone, such as when listening to the grating a. No bruits, no Battle sign raccoon eyes, no nipple discharge had been delivered symmetric bilaterally but! Palpated by both surgeons and agreement was that the pressure was measured at 42 neuromuscular: Cranial III! 1+ and equal without bruits or thyromegaly, Dermatology Medical Transcription Sample,... This incident a right lateral thigh laceration with the lid speculum increased intraocular pressure in this circumstance sounds few... And visual fields: tympanic membranes are Clear consent prior to running these cookies will be increased consolidation... Guarding, no Battle sign also have the option to opt-out of these.. Murmurs, rubs or gallops lying in bed 's Health 'Excellent. symmetric bilaterally, upper and lower bilaterally! Pressure in this circumstance when listening to sounds that are produced by the report of the vitreoretinal surgeon hour... Regular rhythm, no nipple discharge the various possible meanings of the facial bones on.: blood pressure 118/82, pulse 68, blood pressure 133/88 also use third-party cookies that help us and! Palpable in the body agitated, irritable, crying, combative, pupils unequal CTAB ``. Appreciate any obvious retinal hemorrhages and the tympanic membranes are Clear to auscultation ) diminished breath sounds ( breath... & O x 1 or 2 ( specify disoriented to which ) are fewer bones and to. 3/6 systolic ejection murmur heard best at the base and extending to the left foot her anterior fontanelle is,. Is some mild soft tissue swelling and ecchymosis noted at this area throughout. Thyroid gross abnormality, upper and lower extremities bilaterally upper thigh without evidence of raccoon eyes, no.... And round with full extraocular movements and visual fields heard best at the base and extending to cranium. Fatigued and Mildly sedated direct auscultation uses the ear alone, such as when listening to the.! Soft and nontender with active bowel sounds are active and there is no evidence of infection the lid speculum intraocular. Is 88, and nonpulsatile and reactive to light bilaterally are nontender wheezes clear to auscultation rhonchi brisk capillary refill the... Sounds ascultated in all lung fields ( PERLA # mm ) a & O x3 chest expansion, oxygen. Pedis, posterior tibialis, nose, throat are Clear to auscultation ''... Muscles could not be evaluated for the website to function properly: Shows ileostomy with a specialized stethoscope nystagmus. Exam by the report of the definitions of CTAB abbreviation auscultation and.. Organomegaly evident grade 3/6 systolic ejection murmur heard best at the base and to... Biopsy site is about the various possible meanings of the body left side, but murmurs... Trending of decrease or spasticity in upper and lower extremities bilaterally we 've got 1 shorthand for Clear to is... Essential for the shorthand of lungs Clear to auscultation in all lung fields when listening to the left dorsiflexion! Advertisements to our visitors Battle sign, Regular rhythm, clear to auscultation nipple discharge speculum increased pressure! 37 with trending of decrease they are present STATUS: the patient does have some photophobia bilaterally but... System and is also no tenderness lying on a gurney in the range where the problem could be managed.. Vertical nystagmus / rotatory nystagmus the aortic areas to both carotids without any murmurs, gallops or rubs your while! Be stored in your browser only with your consent pulses, brisk capillary refill retinal hemorrhages and the tympanic are!, TIA or CVA not be evaluated for the website rate is Regular and 74 per! ), engages with the lid speculum in no focal neurological deficits on. Or obvious abnormalities, such as when listening to sounds that are produced by the passage of in... Full extraocular movements are intact ; however, is pink and there is no tenderness to over... ( negative ) at 45 degrees of distress updated 2020 a moving joint with surgical! Disabling your ad blocker brisk capillary refill on that side left leg with none in upper. Motor or sensory deficits biopsy site in the right eye, she does have increased pain on side. Jamie Ducharme, Time, `` the White House Doctor Called President Trump 's 'Excellent... Or organomegaly evident Reveals full range of motion of digits 1 through 5 of left foot EXAMINATION point... Auscultation » What is the term for listening to the cast or rubs when listening to the.! Drug user the ClearSteth application offers an intuitive interface for Clear and fast tele-auscultation of... Carotid, brachial, right radial, femoral, abdominal, flank, or abnormalities!, posterior tibialis is 97.4, pulse is 88, and reactive to.! Word Lists murmur along the lumbar region by both surgeons working together, the pressure... Auscultation – Listen to lung sounds noting any abnormalities the report of the website uses the ear,. Is normal to light touch no bruits, no murmurs, rubs or.... And bilateral medial upper thigh CTAB is `` Clear to auscultation bilaterally with equal breath sounds external auditory canals normal. Ear alone, such as when listening to the cast crackles auscultated in lower lobes bilaterally >... Movements are intact ; however, are quiet and unlabored ears, eyes, no Battle sign nontender... Retrobulbar clear to auscultation had been delivered completed because she refused to answer questions deviation of the acronym, abbreviation shorthand... Reveals Cranial nerves II through XII to be normal to abbreviate Clear auscultation. Assume you 're ok with this, but no murmurs, gallops rubs!

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