Physical Examination

Verbatim Examination Finding
BILATERAL ANTERIOR ARM / WRITSTS FAIRLY ERYTHEMATOUS RASH, SCALY NOW, NON PRURITIC, IMPROVED FROM PREVIOUS VISIT STILL ONGOING SINCE 16MAY2020
PAPULES ON RIGHT BASE OF THUMB AND WRIST TO FOREARM, AND DERMATITIS ON THE RIGHT HAND.
L LATERAL ASPECT OF EYE- SLIGHT SWELLING AND PROMINENT VESSELS
.5CM ECHYMOSIS AT THE INJECTION SITE IN LEFT DELTOID
LEFT UPPER ARM MILDLY HYPERSENSITIVE AND MILD SOFT, TENDER SWELLING: 3CM AREA AROUND INJECTION SITE; NO REDNESS; IT IS TENDER
5CM INDURATION AT SITE OF INJECTION (LUE - DELTOID AREA)
SKIN: NO RASH NOTED. REDNESS MEASURING 18 UNITS ON THE MEASURING DEVICE, WITH ERYTHEMA AT INJECTION SITE IN LEFT DELTOID, MILD TENDERNESS TO PALPATION OF INJECTION SITE. (PLEASE SEE AE NOTE)
MACULAR RASH ON EXPOSED BILATERAL ARMS, UPPER CHEST
TENDERNESS IS PRESENT WITH PALPITATION OF INJECTION SITE IN LEFT DELTOID. NO REDNESS OR SWELLING. THIS IS ABNORMAL AND NOT CLINICALLY SIGNIFICANT
MILD TENDERNESS TO PALPITATION OVER INJECTION SITE
LEFT WRIST EXCORIATION FROM WEARING GLOVES AND WORKING
LIGHT RED, NON-SCALY, NON-EXCORIATED RASH AROUND THE EDGE OF THE BANDAGE SITE
RAISED, RED, NON-BLANCHING, NON-SCALING PATCH APPROXIMATELY 2 CM IN DIAMETER BEHIND LEFT EAR ON SCALP, NO OTHER RASHES
ABLE TO LIFT ARMS AT SHOULDERS TO SLIGHTLY BEYOND 90 DEGREES UNABLE TO BRING ARMS BEHIND BACK, SLIGHT DEFORMITY OF RIGHT 2ND FINGER, MILDLY ENLARGED FINGER JOINTS
RIGHT ELBOW WITH LARGE ERYTHEMA, EXCORIATION COVERED WITH DRESSING, B/L PALMS WITH RESOLVING EXCORIATIONS, R KNEE BRUISE AND R THIGH EDEMA
MILD BRUISING OF DELTOID, MILD DISCOLORATION, 1 CM IN DIAMETER, CIRCULAR, NONTENDER
IMPACTED CERUMEN OF THE LEFT EXTERNAL EAR
3MM VESICULAR LESION ON LEFT LOWER LIP WITH NO ASSOCIATED CELLULITIS
LEFT LOWER LIP WITH TWO LESIONS, CRUSTED CENTER VESICLE WITH SURROUNDING ERYTHEMATOUS BASE 2MM IN SIZE, NON TENDER
RIGHT HAND 5TH DIP (DISTAL INTERPHALANGEAL JOINT) ABNORMAL RANGE OF MOTION
TENDERNESS AT INJECTION SITE, GUARDED ROM LUE
ECHYMOSIS IN IN MEDIAL LEFT ANTECUBITAL FOSSA
TENDERNESS PRESENT, MILD TENDERNESS TO PALPATION, GUARDED ROM OF LUE
RIGHT LOWER LEG BELOW KNEE MILDLY SWOLLEN COMPARED TO LEFT WITHOUT PITTING EDEMA, MILD INDURATION OVER RIGHT UPPER LATERAL PORTION OF THE LOWER LEG. ALL RELATED TO FRACTURE AS NOTED IN AE
LEFT ARM EXAM- SMALL SWELLING, NO ERYTHEMA, MILD TENDERNESS ON PALPATION, 4X2CM, NO BLISTERS, ABLE TO USE ARM WITHOUT ANY LIMITATION OF MOVEMENT
MILD POSTERIOR PHARYNGEAL ERYTHEMA WITH COBBLESTONING
LEFT LEG SWOLLEN COMPARED TO RIGHT WITHOUT PITTING
MINIMAL ECCHYMOSIS AT LEFT UPPER EXTREMITY INJECTION SITE
MILD TENDERNESS AT INJECTION SITE. LEFT ARM
RIGHT ARM WITH TENDERNESS AT SITE OF INJECTION. NO ERYTHEMA OR SWELLING. FULL RANGE OF MOTION RIGHT SHOULDER
5MM (0.5CM) RESOLVING ECCHYMOSIS RIGHT DELTOID
1CM ECCHYMOSIS ARM AT LEFT DELTOID. NO TENDERNESS OR REDNESS
LEFT SHOULDER WITH MILD DECREASED RANGE OF MOTION. NO ERYTHEMA/SWELLING
TENDERNESS AT INJECTION SITE UPPER LEFT ARM. FULL RANGE OF MOTION LEFT SHOULDER. NO ERYTHEMA OR SWELLING
TENDERNESS TO DIRECT PALPATION AT INJECTION SITE
SORENESS/TENDERNESS AT INJECTION SITE LEFT ARM
MULTIPLE PAPULAR ERYTHEMATOUS NODULES < 1MM SIZE LOCATED ON EXPOSED AREAS ARMS AND LEGS BILATERALLY
TENDER LEFT UPPER ARM TO PALPATION NO EDEMA NO ERYTHEMA
RIGHT INJECTION SITE TENDERNESS TO PALPATION
TENDERNESS TO PALPATION LEFT ARM AT VACCINATION SITE
MILD TENDERNESS AT INJECTION SITE, LEFT ARM
NO ERYTHEMA OR SWELLING AT LEFT ARM INJECTION SITE
FAINT BRUISES, NON TENDER, NO NODULARY EDEMA
10MM INDIRATION AT INJECTION SITE NO REDNESS
HAS A LARGE FLAT RED RASH ON RIGHT SUPRACLAVICULA ALSO ON UPPER BACK.
VERY SMALL LEFT AXILLARY NODE NOT TENDER
BRUISES ON LEFT ARM FROM WORKING ON LAWN MOWER
FAINT AREA ~ 5CM OF REDDNESS OVER VACCINE SITE
TENDER AT THE ANTERIOR OUTER RIGHT MID THORACIC RIBS
MILD ERYTHEMA; CLEAR DRAINAGE NOTED POSTERIOR PHARYNX
BILATERAL NASAL MUCOSAL ERYTHEMA; BILATERAL CLEAR NASAL DRAINAGE
RIGHT ANKLE WITH PAIN ON INVERSION STARTED 02JUN2020 AFTER NEW YOGA ROUTINE; MILD TINGLING IN RIGHT GREAT TOE; RESOLVING TODAY; EXAM NORMAL.
RIGHT LOWER VERMILION BORDER WITH A 4MM AND 6MM NONERYTHEMATOUS, ROUND LESION WITH CLEAR BORDER AND THIN CRUST
SCATTERED, MILDLY ERYTHEMATOUS PAPULAR RASH OVER THE RIGHT UPPER CHEST, APPROXIMATELY 3-4 CM IN DIAMETER. SIMILAR, PATCHY, MILDLY ERYTHEMATOUS PAPULAR RASH TO THE RIGHT SIDE OF HER FOREHEAD, TEMPLE
PAIN IN LEFT HIP WITH STANDING AND TRUNCAL ROTATION
HAS 1X2 CM NON-TENDER, MOBILE NODE IN RIGHT AXILLAE
3CM AREA ON LEFT MEDIAL THIGH WITH LIGHT GREENISH ECCHYMOSIS AND SCATTERED ERYTHEMATOUS PAPULES WITHIN A 6CM AREA
2 BY 2 INCH PATCH OF POISON IVY LEFT UPPER INNER ARM.

Result or Finding in Standard Format
BILATERAL ANTERIOR ARM / WRITSTS FAIRLY ERYTHEMATOUS RASH, SCALY NOW, NON PRURITIC, IMPROVED FROM PREVIOUS VISIT STILL ONGOING SINCE 16MAY2020
PAPULES ON RIGHT BASE OF THUMB AND WRIST TO FOREARM, AND DERMATITIS ON THE RIGHT HAND.
L LATERAL ASPECT OF EYE- SLIGHT SWELLING AND PROMINENT VESSELS
.5CM ECHYMOSIS AT THE INJECTION SITE IN LEFT DELTOID
LEFT UPPER ARM MILDLY HYPERSENSITIVE AND MILD SOFT, TENDER SWELLING: 3CM AREA AROUND INJECTION SITE; NO REDNESS; IT IS TENDER
5CM INDURATION AT SITE OF INJECTION (LUE - DELTOID AREA)
SKIN: NO RASH NOTED. REDNESS MEASURING 18 UNITS ON THE MEASURING DEVICE, WITH ERYTHEMA AT INJECTION SITE IN LEFT DELTOID, MILD TENDERNESS TO PALPATION OF INJECTION SITE. (PLEASE SEE AE NOTE)
MACULAR RASH ON EXPOSED BILATERAL ARMS, UPPER CHEST
TENDERNESS IS PRESENT WITH PALPITATION OF INJECTION SITE IN LEFT DELTOID. NO REDNESS OR SWELLING. THIS IS ABNORMAL AND NOT CLINICALLY SIGNIFICANT
MILD TENDERNESS TO PALPITATION OVER INJECTION SITE
LEFT WRIST EXCORIATION FROM WEARING GLOVES AND WORKING
LIGHT RED, NON-SCALY, NON-EXCORIATED RASH AROUND THE EDGE OF THE BANDAGE SITE
RAISED, RED, NON-BLANCHING, NON-SCALING PATCH APPROXIMATELY 2 CM IN DIAMETER BEHIND LEFT EAR ON SCALP, NO OTHER RASHES
ABLE TO LIFT ARMS AT SHOULDERS TO SLIGHTLY BEYOND 90 DEGREES UNABLE TO BRING ARMS BEHIND BACK, SLIGHT DEFORMITY OF RIGHT 2ND FINGER, MILDLY ENLARGED FINGER JOINTS
RIGHT ELBOW WITH LARGE ERYTHEMA, EXCORIATION COVERED WITH DRESSING, B/L PALMS WITH RESOLVING EXCORIATIONS, R KNEE BRUISE AND R THIGH EDEMA
MILD BRUISING OF DELTOID, MILD DISCOLORATION, 1 CM IN DIAMETER, CIRCULAR, NONTENDER
IMPACTED CERUMEN OF THE LEFT EXTERNAL EAR
3MM VESICULAR LESION ON LEFT LOWER LIP WITH NO ASSOCIATED CELLULITIS
LEFT LOWER LIP WITH TWO LESIONS, CRUSTED CENTER VESICLE WITH SURROUNDING ERYTHEMATOUS BASE 2MM IN SIZE, NON TENDER
RIGHT HAND 5TH DIP (DISTAL INTERPHALANGEAL JOINT) ABNORMAL RANGE OF MOTION
TENDERNESS AT INJECTION SITE, GUARDED ROM LUE
ECHYMOSIS IN IN MEDIAL LEFT ANTECUBITAL FOSSA
TENDERNESS PRESENT, MILD TENDERNESS TO PALPATION, GUARDED ROM OF LUE
RIGHT LOWER LEG BELOW KNEE MILDLY SWOLLEN COMPARED TO LEFT WITHOUT PITTING EDEMA, MILD INDURATION OVER RIGHT UPPER LATERAL PORTION OF THE LOWER LEG. ALL RELATED TO FRACTURE AS NOTED IN AE
LEFT ARM EXAM- SMALL SWELLING, NO ERYTHEMA, MILD TENDERNESS ON PALPATION, 4X2CM, NO BLISTERS, ABLE TO USE ARM WITHOUT ANY LIMITATION OF MOVEMENT
MILD POSTERIOR PHARYNGEAL ERYTHEMA WITH COBBLESTONING
LEFT LEG SWOLLEN COMPARED TO RIGHT WITHOUT PITTING
MINIMAL ECCHYMOSIS AT LEFT UPPER EXTREMITY INJECTION SITE
MILD TENDERNESS AT INJECTION SITE. LEFT ARM
RIGHT ARM WITH TENDERNESS AT SITE OF INJECTION. NO ERYTHEMA OR SWELLING. FULL RANGE OF MOTION RIGHT SHOULDER
5MM (0.5CM) RESOLVING ECCHYMOSIS RIGHT DELTOID
1CM ECCHYMOSIS ARM AT LEFT DELTOID. NO TENDERNESS OR REDNESS
LEFT SHOULDER WITH MILD DECREASED RANGE OF MOTION. NO ERYTHEMA/SWELLING
TENDERNESS AT INJECTION SITE UPPER LEFT ARM. FULL RANGE OF MOTION LEFT SHOULDER. NO ERYTHEMA OR SWELLING
TENDERNESS TO DIRECT PALPATION AT INJECTION SITE
SORENESS/TENDERNESS AT INJECTION SITE LEFT ARM
MULTIPLE PAPULAR ERYTHEMATOUS NODULES < 1MM SIZE LOCATED ON EXPOSED AREAS ARMS AND LEGS BILATERALLY
TENDER LEFT UPPER ARM TO PALPATION NO EDEMA NO ERYTHEMA
RIGHT INJECTION SITE TENDERNESS TO PALPATION
TENDERNESS TO PALPATION LEFT ARM AT VACCINATION SITE
MILD TENDERNESS AT INJECTION SITE, LEFT ARM
NO ERYTHEMA OR SWELLING AT LEFT ARM INJECTION SITE
FAINT BRUISES, NON TENDER, NO NODULARY EDEMA
10MM INDIRATION AT INJECTION SITE NO REDNESS
HAS A LARGE FLAT RED RASH ON RIGHT SUPRACLAVICULA ALSO ON UPPER BACK.
VERY SMALL LEFT AXILLARY NODE NOT TENDER
BRUISES ON LEFT ARM FROM WORKING ON LAWN MOWER
FAINT AREA ~ 5CM OF REDDNESS OVER VACCINE SITE
TENDER AT THE ANTERIOR OUTER RIGHT MID THORACIC RIBS
MILD ERYTHEMA; CLEAR DRAINAGE NOTED POSTERIOR PHARYNX
BILATERAL NASAL MUCOSAL ERYTHEMA; BILATERAL CLEAR NASAL DRAINAGE
RIGHT ANKLE WITH PAIN ON INVERSION STARTED 02JUN2020 AFTER NEW YOGA ROUTINE; MILD TINGLING IN RIGHT GREAT TOE; RESOLVING TODAY; EXAM NORMAL.
RIGHT LOWER VERMILION BORDER WITH A 4MM AND 6MM NONERYTHEMATOUS, ROUND LESION WITH CLEAR BORDER AND THIN CRUST
SCATTERED, MILDLY ERYTHEMATOUS PAPULAR RASH OVER THE RIGHT UPPER CHEST, APPROXIMATELY 3-4 CM IN DIAMETER. SIMILAR, PATCHY, MILDLY ERYTHEMATOUS PAPULAR RASH TO THE RIGHT SIDE OF HER FOREHEAD, TEMPLE
PAIN IN LEFT HIP WITH STANDING AND TRUNCAL ROTATION
HAS 1X2 CM NON-TENDER, MOBILE NODE IN RIGHT AXILLAE
3CM AREA ON LEFT MEDIAL THIGH WITH LIGHT GREENISH ECCHYMOSIS AND SCATTERED ERYTHEMATOUS PAPULES WITHIN A 6CM AREA
2 BY 2 INCH PATCH OF POISON IVY LEFT UPPER INNER ARM.