Reviewed self-breast exam in detail. The patient is alert, awake, and oriented. MMSE 26/30. There is no CVA tenderness. Distal pulses are 1+ and equal. Lungs were clear to auscultation, though the patient had to pause between breaths due to feeling shortness of breath. HEENT: Normocephalic, atraumatic in reference to the cranium. PHYSICAL EXAMINATION: In good health, they can be heard all over the chest. GENERAL: The patient is an alert female, resting comfortably. With careful retraction of the upper lid and both surgeons working together, the intraocular pressure was measured at 42. Has 5/5 strength in upper and lower extremities bilaterally. NEUROMUSCULAR: Cranial nerves II through XII are intact. No evidence of infection. 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. No hepatosplenomegaly. On rectovaginal exam, no masses. There are no abdominal, flank, or back bruits. HEART: Regular rate and rhythm without murmurs, rubs or gallops. HEENT: Reveals pupils equal and round with full extraocular movements and visual fields. Chest/Lungs: Lungs clear to auscultation and percussion, with equal breath sounds bilaterally. EXTERNAL GENITALIA: Normal. CHEST: Examination of the chest reveals equal bilateral breath sounds. The patient exhibits strong distal pulses, brisk capillary refill. There are no crackles, wheezes or rhonchi noted. SKIN: Intact without petechia. GENERAL: The patient is in no acute distress, A&O x3. Bowel sounds are active and there is no tenderness or mass otherwise. This website uses cookies to improve your experience while you navigate through the website. Vital signs: Blood pressure 104/62, pulse is 88, and temperature is 98.5. CV: No gross edema, or significant varicosities. Pupils are equal and reactive to light. Necessary cookies are absolutely essential for the website to function properly. The Complete Resource For MTs! No nystagmus. There is mild palmar erythema. NECK: Supple, nontender without lymphadenopathy. LYMPHATIC: Unremarkable. Cardiac: Heart is rhythmic and regular without any murmurs, gallops or rubs. unlabored breathing No carotid bruits noted on auscultation. Uvula is midline. Oropharynx is unremarkable. INTEGUMENTARY: Without diaphoresis, rash or lesions. Lungs clear to auscultation. 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. Positive bowel sounds. Dorsalis pedis and posterior tibial pulses. CENTRAL NERVOUS SYSTEM: Grossly intact. Heart rate 72 and regular. Neurologic: Nonfocal. Skin: Warm. Coarse lung sounds ascultated in all lung fields bilaterally. The patient is in no acute distress, resting comfortably in bed. The patient is responsive to commands. She has systolic ejection murmur of 2/6. NECK: Supple. No murmurs or gallops. PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished female, who appears to be in no acute distress. The globe was palpated by both surgeons and agreement was that the pressure was in the range where the problem could be managed medically. Follows complex commands, ambulates with a steady gait. 1 ways to abbreviate Lungs Clear To Auscultation updated 2020. The toes are downgoing. Funduscopic examination is normal. EXTREMITIES: No cyanosis, clubbing or edema. appropriately. You also have the option to opt-out of these cookies. Fetal heart tones can also be monitored during pregnancy by auscultation with a specialized stethoscope. increased AP diameter. — Jamie Ducharme, Time, "The White House Doctor Called President Trump's Health 'Excellent.' NECK: Supple without lymphadenopathy. GENERAL APPEARANCE: Well-developed, well-nourished, nontoxic, ambulatory female. 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***. Pupils are equal, round, reactive to light and accommodation. Q: A: What is CTAB abbreviation? No signs of trauma. RECTAL: Rectum is with good rectal tone. …. The ovaries feel normal. The meaning of CTAB abbreviation is "Clear to Auscultation Bilaterally". Uterus is retroverted, is normal. The patient is nontoxic, calm, conversant. Extraocular muscles are intact. Neck is supple without JVD, goiter or carotid artery bruit. There is no tremor, asterixis, or pronator drift. There are no carotid, femoral, abdominal, flank, or back bruits. Physical Examination Words and Phrases for Medical Transcriptionists. Here's the Full Summary of … Neck: Soft and supple. Capillary refill is brisk. Correct response: Extremities warm to touch. Peripheral vascular system is intact. no penile plaques or genital skin lesions, BUS negative. The finger-nose maneuver is normal. She is reluctant to answer questions. HEENT: Head and face: No facial plethora. → Listen to breath sounds on every patient you can if you want to become experienced at this skill. Extraocular muscles could not be evaluated for the same reason. No murmur. Reflexes 2+ symmetric bilaterally, upper and lower extremities. NEUROLOGIC: Cranial nerves III through XII are normal, strength is 5-/5 symmetrically throughout, and sensation is normal to light touch. There is no edema. The process of listening to sounds that are produced in the body. SKIN: Natural in color. We'll assume you're ok with this, but you can opt-out if you wish. GENERAL: A female who appears slightly older than her stated age, in a mild amount of distress. 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. Uvula and tongue are both midline. Pap smear obtained. Otherwise, there is no evidence of raccoon eyes, no Battle sign. Medical Transcription Sample Reports, Examples & Word Lists! Lungs: Good breath sounds with few rhonchi, but no wheezes. Symmetric patellar reflex. The procedure should always form part of an holistic assessment and mu… Medical Transcription Sample Reports, Examples & Word Lists! VITAL SIGNS: Blood pressure 118/82, pulse 102, respirations 18, and temperature 98%. She is cooperative with exam. Crackles auscultated in lower lobes bilaterally R>L. No paradoxical movement noted. LUNGS: Clear to auscultation A&P. Visual fields are full to confrontation. HEART: Regular rate and rhythm without murmur, rub or gallop. HEART: RRR, without murmur. ABDOMEN: Soft, nontender, nondistended. How to abbreviate Clear To Auscultation And Percussion? Axillae have no adenopathy. Auscultation reveals a regular rate and rhythm with normal S1 and S2. GENERAL APPEARANCE: Not acutely distressed, but she is feeling tired. PHYSICAL EXAMINATION: Mucous membranes are moist and pink. Ears, eyes, nose, throat are all within normal limits. There are good bowel sounds. The patient is alert, cooperative and exhibits intact distal sensation in all extremities. No palpable thrills. There is also no tenderness to palpation over the ribs, clavicles, scapula or the extremities. 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. The liver edge is palpable at one fingerbreadth below the right costal margin, somewhat firm, and nonpulsatile. Scant clear discharge is noted. RECTAL: Exam deferred. Sensation is intact throughout. He is following commands verbally. 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. ABDOMEN: Soft and nontender. No rales or rhonchi. The most popular abbreviation for Lungs Clear To Auscultation is: LCTA These cookies do not store any personal information. good joint range of motion without bony deformities, Cerebellar function intact on finger-to-nose and rapid alternating movement. Skin: Clear. Tympanic membranes are clear, without hemotympanum, and there is no septal hematoma. Normal S1, S2. Intact Achilles tendon. 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). Pulses are palpable and equal bilaterally. Nondistended. We'll assume you're ok with this, but you can opt-out if you wish. He is alert and oriented x3. EXTREMITIES: No clubbing, cyanosis or edema noted. Abdomen is soft and nontender. PHYSICAL EXAMINATION: General: He is a pleasant gentleman in no distress. HEART: Regular rate and rhythm, S1 and S2. This website uses cookies to improve your experience. PHYSICAL EXAMINATION: Pap was performed. Cranial nerves are intact. Recent Examples on the Web Pulmonary exam: His lungs were clear to auscultation. She had paraspinal tenderness upon palpation of her levator scapulae muscle and scalene muscles. Nares are patent. Auscultation – Listen to lung sounds noting any abnormalities. EXTREMITIES: Good capillary refill bilaterally. There are no murmurs, rubs or gallops. NECK: Supple. No scleral icterus. She has poor eye contact. A 2/6 systolic ejection murmur. No increased WOB, retractions, or nasal flaring noted. Left foot examination reveals point tenderness with palpation over the left fourth and fifth metatarsal bases. 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Is nondisplaced ; it is mandatory to procure user consent prior to running these cookies may have an on! On your browsing experience are quiet and unlabored any murmurs, rubs or gallops palpation with bilateral paracervical and musculature! Flaring noted the aortic areas to both carotids extremities bilaterally Listen to lung sounds noting abnormalities.