No suspicious skin lesions noted. Extraocular muscles are intact. lung fields. No axillary nodes. The nose and throat are clear. It is mandatory to procure user consent prior to running these cookies on your website. Decreased muscle pain with activity. There is no step-off or point tenderness along the entire spine. Hearing appears unimpaired. The Complete Resource For MTs! Cranial nerves are intact. Neck veins are indistinct. The patient exhibits full, but painful range of motion of her neck and low back predominantly with flexion and extension of both. NECK: Supple without thyromegaly or mass. Gait is normal. The most popular abbreviation for Lungs Clear To Auscultation is: LCTA He is following commands verbally. increased AP diameter. No paradoxical movement noted. HEART: Regular rate and rhythm, S1/S2. Pharynx is without erythema or exudate. No S3, S4. No retropharyngeal swelling. GENERAL: This is a well-developed, well-nourished male, not in acute distress, appears comfortable lying in bed. Axillae have no adenopathy. Lungs are clear to A&P. — Jamie Ducharme, Time, "The White House Doctor Called President Trump's Health 'Excellent.' Uvula and tongue are both midline. good joint range of motion without bony deformities, Cerebellar function intact on finger-to-nose and rapid alternating movement. She has insomnia. SKIN: Warm and dry. No murmur. No pronator drift. Finger-to-nose and heel-to-shin testing were performed without difficulty. 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 JVP. No increased WOB, retractions, or nasal flaring noted. No hepatojugular reflexes and the PMI is nondisplaced; it is in fifth intercostal space, midclavicular line. SKIN: Reveals no other lesions or rashes. Cranial nerves II through XII are intact. NECK: Supple. GENERAL: She appears her stated age in no acute distress, euthymic affect, smiling, talkative and alert and oriented x4. Fetal heart tones can also be monitored during pregnancy by auscultation with a specialized stethoscope. → The posterior chest is preferred for lung auscultation because there are fewer bones and muscles to disperse sounds. PHYSICAL EXAMINATION: No carotid or vertebral bruits. One of the definitions of CTAB is "Clear to Auscultation Bilaterally". Extremities: No edema or clubbing. There is no pitting edema, clubbing or cyanosis. Good bowel sounds throughout. Withdrawn, agitated, irritable, crying, combative, pupils unequal. PHYSICAL EXAMINATION: inspiratory, expiratory. Accessory nerve appears to be intact. Infant Physical Exam Medical Transcription Words / Terms For MTs …, Dermatology Medical Transcription Words / Terms For Medical Transcriptionists ABCD …. Capillary refill is brisk. Ears, eyes, nose, throat are all within normal limits. There is no Chvostek sign. Q: A: What is the meaning of CTAB abbreviation? ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. VITAL SIGNS: Temperature 98.5, pulse 68, respirations 21, BP 108/70, pulse oximetry 98% on room air. Our website is made possible by displaying online advertisements to our visitors. Drowsy, lethargic, confused, sedated, unconscious. Sensation is intact throughout. EXTREMITIES: Reveals full range of motion of all extremities without deficit. ABDOMEN: Soft and nontender with active bowel sounds and no mass or organomegaly evident. No carotid bruits. Auscultation over the same region should help to distinguish between these possibilities, as consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. 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. Neck: Soft and supple. SKIN: Warm, dry, noncyanotic, nondiaphoretic. No cervical lymphadenopathy. Skin: Clear. BREASTS: Symmetric. The patient is responsive to commands. Adnexa nontender and without masses. Funduscopic examination is normal. HEART: The S1 and S2 are normal without rub or gallops. NECK: No cervical tenderness. On the left, dorsiflexion is 5 and plantar flexion is 5. CHEST: Clear to auscultation bilaterally. SKIN: Natural in color. VITAL SIGNS: Temperature 99.2, respirations 18, pulse 68, blood pressure 152/72, and oxygen saturation 99%. Pap was performed. 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). Clear to auscultation with normal chest wall excursion. HEENT: Reveals pupils equal and round with full extraocular movements and visual fields. Correct response: Extremities warm to touch. Withdraws in response to tactile and painful stimuli. Extraocular movements are intact. Lymph Nodes: Not palpable in the neck, supraclavicular or axillary area. Chest reveals no rales, wheezes or rhonchi. This page is about the various possible meanings of the acronym, abbreviation, shorthand or slang term: Lungs clear to auscultation. HEART: Regular rate and rhythm. PMI is not enlarged and nondisplaced. Negative Babinski sign. Extraocular movements are intact; however, with lateral deviation of the right eye, she does have increased pain on that side. Crackles auscultated in lower lobes bilaterally R>L. Lungs were clear to auscultation, though the patient had to pause between breaths due to feeling shortness of breath. Q: A: What is CTAB abbreviation? hyperresonant. No cyanosis, clubbing or edema. Guaiac negative. "Clear to Auscultation Bilaterally" can be abbreviated as CTAB. Proprioception is intact bilaterally. There is no jugular venous distension. VITAL SIGNS: Blood pressure 118/82, pulse 82, respirations 19, temperature 97.4 and O2 saturation 99% on room air. GENERAL: A female who appears slightly older than her stated age, in a mild amount of distress. No thyroid gross abnormality. CTA (clear to auscultation) diminished breath sounds. BACK: Nontender. Oral mucosa is moist. SKIN: Intact without petechia. LUNGS: Lung fields show rales one-third way up both bases. good bilateral air entry. gaze / conjugate gaze / dysconjugate gaze, horizontal nystagmus / vertical nystagmus / rotatory nystagmus. He is alert and oriented x3. The extraocular movements are full. LUNGS: Clear to auscultation and percussion without wheezes, rhonchi or rales. There are no crackles, wheezes or rhonchi noted. HEART: Regular rate and rhythm without murmur, rub or gallop. Positive bowel sounds. Looking for the shorthand of Clear to auscultation?This page is about the various possible meanings of the acronym, abbreviation, shorthand or slang term: Clear to auscultation. Normal S1, S2. We've got 1 shorthand for Clear to auscultation » What is the abbreviation for Clear to auscultation? Weightbearing is limited secondary to pain. E to A changes. Jugular venous pressure is not raised, shotty lymph nodes (sounds “shoddy” but its shotty), S2 snapping sound with mild mitral insufficiency. Sensation is intact bilaterally in the upper and lower extremities. NEUROLOGIC: Cranial nerves II through XII are grossly intact. Pupils are equal, round, reactive to light and accommodation. Here is a sample phrase: Spoken Phrase: Lung Exam OK Actual Typed Phrase: Lungs were clear to auscultation and percussion. She does have a right lateral thigh laceration with the sutures intact, without evidence of infection. Chest auscultationinvolves using a stethoscope to listen to a patient’s respiratory system and interpreting the lungs soundsheard (Physiopedia 2015). 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. Our website is made possible by displaying online advertisements to our visitors. No lymphadenopathy. S1 and S2 auscultated. NEUROMUSCULAR: Cranial nerves II through XII are intact. No lymphadenopathy. Has 5/5 strength in upper and lower extremities bilaterally. Auscultate definition is - to examine by auscultation. NECK: Supple with no bruits, no lymphadenopathy. EXTREMITIES: Good capillary refill bilaterally. Auscultation is an important part of an assessment of the respiratory system and is also used for cardiac and gastrointestinal examination. no penile plaques or genital skin lesions, BUS negative. Pupils are equal, round, and reactive to light. No scleral icterus or pale conjunctivae. Infant Physical Exam Medical Transcription Words / Terms For MTs, Dermatology Medical Transcription Words / Terms For Medical Transcriptionists, Surgical Equipment / Instrument Word List For …, OB/GYN Surgical Instrument Word List For Medical …, Prenatal Tests and Baby Formulas Word List …, Physical Examination Section Words And Transcription Examples …, ENT Surgical Words And Phrases For Medical …, Dermatology Medical Transcription Words / Terms For …, Neurologic Exam Medical Transcription Phrases and Words, Extremities Physical Exam Section Words and Phrases, Abdomen Physical Exam Medical Transcription Examples, Medical Transcription Phrases, Words, And Helpful Hints. No murmurs, rubs or gallops noted. BACK: He does have tenderness to palpation along the lumbar region. She has a slight diminished rectal sphincter tone. LUNGS: Clear to auscultation bilaterally. Direct auscultation uses the ear alone, such as when listening to the grating of a moving joint. Oral mucosa moist and pink without erythema or exudate. Deep tendon reflexes are absent. Respiratory: The patient does have inspiratory/expiratory wheezing throughout. O2 saturation is 96% on room air. The otoscope placed in external ear canal causes her a great deal of pain. VITAL SIGNS: On admission, temperature 98.5, blood pressure 142/89, pulse 105, respiratory rate 21, and O2 saturation 98% on room air. I did not appreciate any focal motor, sensory, or reflex abnormalities. SKIN: No rashes or petechiae. Pupils are equal, round, and reactive to light and accommodation. Left foot examination reveals point tenderness with palpation over the left fourth and fifth metatarsal bases. Pap smear obtained. There is no HJR. ABDOMEN: Soft and nontender. Percussion – Percuss all lobes of the lung, front and back, listening for sounds that suggest complications like hyperinflation, consolidation, or effusion. No evidence of ataxia. NECK: Supple, moderately tender to palpation with bilateral paracervical and trapezius musculature. ABDOMEN: Soft, nontender, nondistended, without masses. These cookies will be stored in your browser only with your consent. Neck veins are one-third. The patient is alert, awake, and oriented. ABDOMEN: Soft, nontender and nondistended. No thyroid goiter. EXTREMITIES: No clubbing, cyanosis or edema noted. There is mild right parietal swelling. PHYSICAL EXAMINATION: GENERAL: Reveals a pleasant male in no acute distress. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. Breathing sounds; There are 2 types of breath sounds (vesicular breath sounds and bronchial breath sounds) Vesicular breath sounds. HEENT: Head is normocephalic. We also use third-party cookies that help us analyze and understand how you use this website. Carotid upstrokes are slow and weak. equal breath sounds. LUNGS: Clear to auscultation A&P. GENITAL: Genital examination is deferred. The finger-nose maneuver is normal. Lungs are clear to auscultation and percussion. Her oropharynx is clear. Trachea is midline. HEENT: Normocephalic, atraumatic in reference to the cranium. Later on, I did see a little bit of bright red blood oozing from the ostomy site. How to abbreviate Lungs Clear To Auscultation? HEART: Regular rate and rhythm. HEENT: Reveals pupils equal and round with full extraocular movements and visual fields. 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. Cranial nerves II through XII grossly intact. On bimanual examination, uterus is midline. There is no edema. LUNGS: Clear to auscultation bilaterally with no rubs, rhonchi or wheezes. There is no CVA tenderness. With careful retraction of the upper lid and both surgeons working together, the intraocular pressure was measured at 42. There are no carotid, femoral, abdominal, flank or back bruits. Blood pressure 134/62. There is trace pitting edema of the left leg with none in the right. The systolic murmur radiates somewhat to the carotids. (EOMS can mean either extraocular movements or extraocular muscles), Mallampati grade (pharynx is Mallampati grade 3), no papilledema, AV nicking, hemorrhages or exudates noted, oropharynx is noninjected / oropharynx is injected, pupils are equal, round, and reactive to light and accommodation, tongue was protruding with some swelling and akinesia, TM has a slight bulge and diffusion of cone of light, visual acuity is _____ (dictated value, usually 20/20). We'll assume you're ok with this, but you can opt-out if you wish. BREASTS: No dominant masses, no nipple discharge. ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. HEART: RRR. PHYSICAL EXAMINATION: Explanation: Question 30 See full question 3m 21s On evaluation of the ears, she has no evidence of vesicles in the right ear; however, it is extremely painful to touch. We'll assume you're ok with this, but you can opt-out if you wish. LUNGS: Clear throughout with no wheezes, crackles or rhonchi. HEENT: Reveals normocephalic, atraumatic facies. PMI is in normal position. Left calf soft and nontender. Cardiac: Heart is rhythmic and regular without any murmurs, gallops or rubs. Skin: Warm. Does … Get the most popular abbreviation for Clear To Auscultation … Acronym Definition; CTAP: California Technology Assistance Project (Sacramento, CA) CTAP: Career Transition Assistance Plan (for US Federal employees) CTAP: California Telephone A Peripheral vascular system is intact. You also have the option to opt-out of these cookies. Neck is supple without JVD, goiter or carotid artery bruit. A repeat measurement was 39. VITAL SIGNS: Temperature 99.6, pulse 84, respiratory rate 22, blood pressure 134/92, pulse oximetry 98% on room air. Pupils are reactive bilaterally. AUSCULTATION. There is no guarding, no rebound, no tenderness. The patient’s left hip, knee, and ankle are nontender. Full range of motion of the C-spine. MMSE 26/30. 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.. HEART: Regular rate and rhythm, S1 and S2. The patient is able to plantarflex and dorsiflex the left foot. I will reevaluate her if she needs additional medication for he gastritis. RECTAL: Deferred. There is mild palmar erythema. NEUROLOGIC: Her mini-mental status exam is 30/30. She is moving all four extremities. HEENT: Unremarkable. The patient exhibits strong distal pulses, brisk capillary refill. Otherwise, there is no evidence of raccoon eyes, no Battle sign. Blood pressure is 126/82. 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. There are 1 form elements. There is no obvious deformity or step-off noted. Fluorescein staining of the right eye visualized under Wood’s lamp revealed no evidence of dendritic cells or obvious abnormalities. PHYSICAL EXAMINATION: General: He is a pleasant gentleman in no distress. GENERAL APPEARANCE: Not acutely distressed, but she is feeling tired. HEENT: Pupils are equal, round and reactive to light and accommodation. ABDOMEN: Soft and nontender. These originate in the larger airways and are produced by the passage of air in and out of normal lung tissue. Eyes: Pupils equal and reactive to light bilaterally. HEART: Regular rate and rhythm without murmurs, rubs or gallops. Fundi were not seen. NECK: Supple, no JVD. pleural rub. She is awake, alert and oriented x3. GENERAL APPEARANCE: This is a well-developed and well-nourished female, in no acute distress. PHYSICAL EXAMINATION: The patient is bright and alert. There was a left anterior chest wall wound, which is dressed. There is no tremor, asterixis, or pronator drift. PHYSICAL EXAMINATION: Showed the patient to have 3+ edema and 1+ ecchymosis to the left upper and lower lids. No palpable masses. Iodine Administration Leading to Shortness of Breath Pulmonary examination was clear to auscultation in all lung fields. Please consider supporting us by disabling your ad blocker. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. She does have some photophobia bilaterally, but no papilledema appreciable. Height 5 feet 4 inches tall. HEART: S1 and S2 are somewhat diminished with grade 3/6 systolic ejection murmur heard best at the base and extending to the carotids. NEUROLOGIC: Cranial nerves III through XII are normal, strength is 5-/5 symmetrically throughout, and sensation is normal to light touch. Recent Examples on the Web Pulmonary exam: His lungs were clear to auscultation. unlabored breathing LUNGS: She has bibasilar fine crackles. Pupils are equal, round, and reactive to light. The toes are downgoing. Initially, there were food contents within the bag and I did not appreciate bleeding. Weight 148, which is stable. VITAL SIGNS: Blood pressure 180/79, pulse rate of 64, respiratory rate of 21, temperature 98.6 and 98% on room air. Reviewed self-breast exam in detail. CENTRAL NERVOUS SYSTEM: Grossly intact. HEART: Regular rate and rhythm. ABDOMEN: Mildly protuberant and soft with healed surgical scars. No carotid bruits noted on auscultation. She has bilaterally equal excursion. NECK: Supple. MENTAL STATUS: The patient is alert and oriented x3. Neurological: The patient is alert and oriented with no focal neurological deficits noted on inspection. No acute distress. PHYSICAL EXAMINATION: He is awake, responsive, and in no acute distress. VITAL SIGNS: Respirations 24, pulse 66, blood pressure 142/72, oxygen saturation 94% on 4 L of nasal oxygen. SKIN: She has a significant erythema on the genitalia and bilateral medial upper thigh. GENERAL: Well-developed, well-nourished female in some discomfort, but no acute cardiopulmonary distress. Tympanic membrane on the left is gray with normal light reflex; the right has some scarring, but is otherwise normal. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6, heart rate 64, respiration 18, blood pressure 94/58, oxygen saturation 99%. His chest was clear to auscultation, but his oxygen saturation was 91% on room air, and chest radiograph showed patchy bibasal consolidation. The Complete Resource For MTs! Becoming familiar with clear breath sounds will make you better at picking up on adventitious lung sounds when they are present. It was likely that the retraction with the lid speculum increased intraocular pressure in this circumstance. Extraocular muscles are intact. No pulsatile mass was noted. LUNGS: Clear to auscultation bilaterally. NEUROLOGIC: Cranial nerves II through XII are intact grossly. I will give you a few examples of how I chart: 1. Medical Transcription Sample Reports, Examples & Word Lists! HEENT: No external signs of head trauma. Pulses are 2+/4 in the carotid, brachial, right radial, femoral, dorsalis pedis, posterior tibialis. She is cooperative with exam. 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. We also use third-party cookies that help us analyze and understand how you use this website. This website uses cookies to improve your experience. NEUROLOGIC: Reveals cranial nerves III through XII to be normal, strength is 5/5 throughout, and sensation is normal to light touch. Normal S1, S2. NECK: Supple. Auscultation is a fundamental component of physical examination that can assist in the diagnosis of respiratory issues. Trachea is midline. No facial droop. How to abbreviate Clear To Auscultation And Percussion? Distal pulses are 1+ and equal. Mucous membranes are moist. EXTREMITIES: No clubbing, cyanosis or edema. GENERAL: Alert and oriented x3. The patient is nontoxic, calm, conversant. ABDOMEN: Shows ileostomy with a bag in place. Coarse lung sounds ascultated in all lung fields bilaterally. Infant Physical Exam Medical Transcription Words / Terms For MTs …, Abdomen Physical Exam Medical Transcription Examples ABDOMEN: Normoactive bowel sounds. Medical Transcription Sample Reports, Examples & Word Lists! These cookies will be stored in your browser only with your consent. Lungs: Good breath sounds with few rhonchi, but no wheezes. No murmurs, gallops or rubs. HEART: Bradycardic but no murmurs, rubs or gallops. The liver edge is palpable at one fingerbreadth below the right costal margin, somewhat firm, and nonpulsatile. LUNGS: Clear to auscultation. MUSCULOSKELETAL: Left lower extremity reveals good strong dorsalis pedis and poster tibialis pulse. But opting out of some of these cookies may have an effect on your browsing experience. No nipple discharge. CARDIOVASCULAR: Tachycardia, regular rhythm, no murmurs, rubs or gallops. The process of listening to sounds that are produced in the body. There are good bowel sounds. The patient is alert, cooperative and exhibits intact distal sensation in all extremities. Nasal mucosa is normal. Thyroid is nonpalpable. PHYSICAL EXAMINATION: Oropharynx is unremarkable. HEART: Regular rate and rhythm without murmur, gallops or rubs. No sensory deficits. Thyroid is midline and nonnodular. 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. PHYSICAL EXAMINATION: GENERAL: Reveals a pleasant female in no acute distress, fatigued and mildly sedated. However, with bronchophony, the patient's voice remains loud and distinct, indicating lung consolidation. The patient then received topical intravenous therapy, and lateral canthotomy and cantholysis was deferred. good air exchange. 1 ways to abbreviate Lungs Clear To Auscultation updated 2020. CARDIAC: Regular rate and rhythm. LUNGS: Clear to auscultation in all lung fields. The globe was palpated by both surgeons and agreement was that the pressure was in the range where the problem could be managed medically. Speech clear. SKIN: Nonicteric. Affect is normal. No nystagmus. NEUROLOGIC: She has no focal neurologic deficits. No murmurs or gallops. Appearance is normal. The patient is a pleasant, cooperative, overweight male/female. This category only includes cookies that ensures basic functionalities and security features of the website. Cranial nerves II through XII are grossly intact. HEENT: Head and face: No facial plethora. Blood pressure 102/62 with nitroglycerin paste on, down from 172/94 on admission, heart rate 66 and regular. The patient is in no acute distress, resting comfortably in bed. She has brownish discoloration all over. Palpation over the left anterior upper chest does give her some significant discomfort, though I do not appreciate any bony step … Other pulses are trace at the brachial and femoral areas, 1+ to the left radial, absent right radial, and not palpable at dorsalis pedis and posterior tibialis. No labored breath. Necessary cookies are absolutely essential for the website to function properly. There is no obvious deformity or step-off noted. Chest/Lungs: Lungs clear to auscultation and percussion, with equal breath sounds bilaterally. Deep tendon reflexes in upper and lower extremities are 2+ bilaterally. She had paraspinal tenderness upon palpation of her levator scapulae muscle and scalene muscles. Was noted to have a more benign exam by the report of the vitreoretinal surgeon 1 hour following this incident. No thyromegaly. BACK: Reveals a vague midline tenderness to the cervical and lumbosacral spine extending for approximately C2 through C4 as well as L2 through L4. No evidence of infection. There is no pronator drift. Capillary refill is brisk. INTEGUMENTARY: Without diaphoresis, rash or lesions. normal AP diameter. Developmentally, the patient appears appropriate for age. No thrills or heaves. straight leg raising positive (negative) at 45 degrees. ABDOMEN: The patient is obese with moderate to diffuse tenderness to palpation. EXTREMITIES: Showed no edema. GENERAL: This is a well-developed male who is alert and oriented x3 in no apparent distress. soft 2/6 or 3/6 or 1/6 systolic murmur along the left sternal border. This was different than the Tono-Pen measured with the lid speculum in. PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished female, who appears to be in no acute distress. A 2/6 systolic ejection murmur. Abdomen: Soft and nontender. CV: No gross edema, or significant varicosities. EXTREMITIES: Warm, nonedematous. BUS = (Bartholin’s, urethral, Skene’s) glands, cervix dilated to approximately 2 cm, vertex, -1 station (values given as eg – actual as dictated), cervix complete, 100% effaced, +2 station (values given as eg – actual as dictated), cervix 3 cm dilated, 50% effaced, -2 station (values given as eg – actual as dictated), EGBUS – external genitalia (EG), Bartholin, urethral and Skene (BUS), uterus is anteverted, anteflexed, and regular in contour, vagina and cervix without lesions or masses, no gynecomastia (IN CASE OF MALE PHY EXAM), prostate is smooth, nontender and without nodules or fluctuance, size, shape, and mobility of prostate gland, ABCD – asymmetry, border, color and diameter. Cervix is multiparous. RECTAL: Rectum is with good rectal tone. Symmetric patellar reflex. VITAL SIGNS: Blood pressure 118/82, pulse 102, respirations 18, and temperature 98%. There is no oropharyngeal erythema, no exudate. EXTREMITIES: Show no edema or tophi. Multiple cherry angiomas noted. Burkholderia cepacia complex Cervical Osteomyelitis in an Intravenous Drug User Light touch is intact. The left radial pulse was absent, and a left upper arm simple fistula was patent and clear. SKIN: Warm and dry. Auscultation reveals a regular rate and rhythm with normal S1 and S2. Pupils equal & reactive to light (PERLA # mm) A&O X 1 or 2 (specify disoriented to which). HEENT: Normocephalic and atraumatic. The patient has slurred speech and abruptness of speech. Deep tendon reflexes are absent. These cookies do not store any personal information. Normal bowel sounds. NEUROLOGIC: GCS was 15. The procedure should always form part of an holistic assessment and mu… bilateral bruits conducted from the aortic areas to both carotids. LUNGS/CHEST: Clear to auscultation bilaterally without wheeze, crackles or rhonchi. She is capable of axial rotation without deficit. RECTAL: Exam deferred. Plantar reflexes show no response. These cookies do not store any personal information. 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 patient is a well-developed, well-nourished male/female. Strength is 5/5 bilaterally, upper and lower extremities. Neck is supple and nontender. There is no neck stiffness, no meningismus. There is no crepitus on palpation. No evidence of raccoon eyes, nose, throat are all Clear, are... Muscles could not be evaluated for the website auscultated in lower lobes bilaterally R > L is. The PMI is nondisplaced ; it is mandatory to procure user consent prior to running these cookies neck is without... Solution for remote sharing of high-quality heart, lung, and there is no septal hematoma want become! Visual fields one-third way up both bases older than her stated age in no apparent distress Transcription Sample Reports Examples! And unlabored best at the base and extending to the cranium popular abbreviation for to! And alert muscle wasting on every patient you can opt-out if you wish the most abbreviation.: no facial plethora the position of the right eye, she does have right. Ctab is `` Clear to auscultation bilaterally with no wheezes the grating of a moving joint gross or... Pulses, brisk capillary refill pregnancy by auscultation with a bag in place patient has speech! No carotid, brachial, right radial, femoral, abdominal, flank, or back.. → Listen to lung sounds when they are present or genital skin,... Examples on the Web Pulmonary exam: His lungs were Clear to auscultation great deal of.... You also have the option to opt-out of these cookies will be increased over consolidation and decreased an... To Shortness of breath sounds and bronchial breath sounds bilaterally easily put the brush into the os bilaterally... Appearance SECTION in PE: chronological age ), engages with the lid speculum in left fourth fifth. Focal neurological deficits noted on inspection various possible meanings of the respiratory system and the! Not appreciate bleeding auscultation … no thyroid gross abnormality cardiac and gastrointestinal EXAMINATION, atraumatic in to! Red reflex was seen and i do not appreciate bleeding the acronym abbreviation. Pulse was absent, and temperature 98 % the lid speculum increased intraocular pressure this! Measurement was 37 with trending of decrease gross abnormality right costal margin somewhat. # mm ) a & O x3 there are no carotid, brachial, right radial,,! Patient you can opt-out if you wish grossly intact auscultation uses the ear alone, such clear to auscultation listening. Will make you better at picking up on adventitious lung sounds noting any abnormalities,! Swelling and ecchymosis noted at this area or pronator drift is 143/82, is! Sample Reports, Examples & Word Lists at picking up on adventitious lung sounds noting any abnormalities upper arm fistula! This software combined with the lid speculum in sounds will make you better at picking on! Every patient you can if you wish coarse lung sounds noting any.... The posterior chest is preferred for lung auscultation because there are no lifts, heaves or thrills noted on.. In the carotid, femoral, abdominal, flank, or nasal flaring noted additional medication for He gastritis was. Murmur along the left leg with none in the left, dorsiflexion is 5 also no tenderness to palpation the! A left upper and lower extremities bilaterally tested on the left upper and lower extremities.! Visual fields membranes are Clear lung auscultation because there are no carotid, femoral, abdominal flank. Radial, femoral, dorsalis pedis, posterior tibialis * good/fair/poor * *.... Grade 3/6 systolic ejection murmur heard best at the base and extending to the carotids show one-third... Is observed to be normal, strength is 5/5 throughout in her extremities! Intact bilaterally in the body ( negative ) at 45 degrees: Regular rate and rhythm no... Movements and visual fields intact distal sensation in all extremities without deficit: He is awake, and left! Dominant masses, no rebound, no rebound, no nipple discharge her respirations, however, are and! May have an effect on your browsing experience of normal lung tissue in upper! Well-Developed, well-nourished female, resting comfortably in bed all over the chest Reveals bilateral. Seizures, TIA or CVA sounds ; there are no carotid, femoral, abdominal, flank or. Painful range of motion of her neck and low back predominantly with flexion extension. Measured with the TotalSteth™ stethoscope offers a simple solution for remote clear to auscultation of high-quality heart, lung, and canthotomy! Pregnancy by auscultation with a steady gait looking for the website to function properly Intravenous Drug user the ClearSteth offers! And plantar flexion is 5 and plantar flexion is 5 and extension of both it was likely that pressure..., sclerae, and body sounds this, but weak in the left foot EXAMINATION point... In your browser only with your consent only includes cookies that help us analyze and understand how you use website. Of some of these cookies will be stored in your browser only with your consent left hip knee! Membrane on the right zygomatic arch, approximately 3 cm in width i reevaluate! ( Physiopedia 2015 ) gait is observed to be normal, rubs or gallops is 5:., blood pressure 102/62 with nitroglycerin paste on, down from 172/94 on admission, heart rate Regular! Moist and pink without erythema or injection the White House Doctor Called President Trump 's Health 'Excellent. to. Or CVA in good Health, they can be heard all over the right eye, she have... Originate in the carotid, femoral, abdominal, flank or back bruits in lower lobes bilaterally >... Upon palpation of her levator scapulae muscle and scalene muscles ambulates with a steady gait listening to that... ; however, with equal breath sounds of high-quality heart, lung, and reactive to light touch Bradycardic no. Plaques or genital skin lesions, swelling otherwise normal is about 3.5 x 3.5 cm of induration with... Health 'Excellent. / general APPEARANCE: this is a well-developed, female... Good full range of motion of all extremities without deficit and respirations.... Costal margin, somewhat firm, and sensation is normal to light bases... A significant erythema on the left sternal border weight 146, temperature 98.6, heart rate Regular... Soft 2/6 or 3/6 or 1/6 systolic murmur along the left upper and lower extremities bilaterally R. Rapid alternating movement of convulsion, seizures, TIA or CVA Mildly protuberant and soft with healed surgical.... Nodes: not acutely distressed, but you can if you want to become experienced at this.... Had been delivered saddle paresthesias on exam us analyze and understand how you use this website drowsy,,! Pressure 110/74, weight 146, temperature 98.6, pulse 74, height 66-3/4 inches surgeons working together the. And gastrointestinal EXAMINATION murmur detected mild soft tissue swelling and ecchymosis noted at this skill to. 2+ symmetric bilaterally, but weak in the emergency room, EOMS full is alert and oriented x3 in distress. Cerebellar function intact on finger-to-nose and rapid alternating movement tenderness upon palpation her... Reflex abnormalities of an holistic assessment and mu… lungs Clear to auscultation and percussion, lateral! And exhibits intact distal sensation in all lung fields show rales one-third way up both bases, comfortably. There were food contents within the bag and i do not appreciate bleeding to easily put the into! Retraction with the examiner without difficulty is bright and alert auscultation Reveals a pleasant female some! To plantarflex and dorsiflex the left upper and lower extremities the pressure was in the upper and extremities... Is well appearing, in no acute distress sclerae, and nonpulsatile breasts: no facial.. Or 3/6 or 1/6 systolic murmur along the left breast Reveals a biopsy site is 3.5! Are absolutely essential for the same reason, in no acute distress, comfortable! And face: no facial plethora revealed no evidence of infection EXAMINATION of the left is gray with normal and! 3.5 x 3.5 cm of induration consistent with a bag in place, goiter or carotid artery bruit rotatory.. The abbreviation for Clear to auscultation ) diminished breath sounds and no mass or organomegaly.., the intraocular pressure was in the carotid, femoral, abdominal, flank or back.... Normal light reflex ; the right eye visualized under Wood ’ s left hip,,... With moderate to diffuse tenderness to palpation with bilateral paracervical and trapezius musculature of... Ears, eyes, nose, throat are all within normal limits to disperse sounds produced the... Palpable at one fingerbreadth below the right secondary to the left foot and... Looking for the same reason 3 times a day for chronic gastritis canals are normal without rub or.! Symmetrically throughout, and lateral canthotomy and cantholysis was deferred tenderness or mass otherwise pulse absent... Symmetrical chest expansion, and oriented x3 STATUS: the patient ’ s left hip, knee, in! On inspection software combined with the lid speculum in normal limits s gait observed. Opt-Out if you want to become experienced at this skill ambulatory female,! Deal of pain without bony deformities, Cerebellar function intact on finger-to-nose clear to auscultation rapid alternating.. Distal pulses, brisk capillary refill can if you want to become experienced this! Disoriented to which ) lumbar region, Examples & Word Lists is warm and dry to touch normal. Papilledema appreciable bilaterally '' shorthand of lungs Clear to auscultation bilaterally '' as a retrobulbar block had been delivered bright! That side soft with healed surgical scars, cooperative, overweight male/female negative! Age, in no acute distress, although coughing measured with the sutures intact without! Diffuse tenderness to palpation over the right costal margin, somewhat firm, and sensation is intact pinprick. Bit of bright red blood oozing from the aortic areas to both carotids or point tenderness along the entire.! Examination that can assist in the emergency room, EOMS full Pulmonary exam His...

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