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• Dragon Naturally Speaking Medical

Medical Examination Commands

About these Examination Commands

This is a series of text commands developed for use in the author's medical practice. Although there are a few complete 'boilerplate' exams, it is strongly recommended that you do not use these boilerplate exams unless they truly reflect your physical examination findings in a specific patient. The majority of the exam-related commands represent exam 'snippets' or small organ or body region descriptions of normal findings. The intention is that these snippets of normal exam be combined with freely dictated aspects of the exam that were not normal or require more in-depth description.

As an example, dictation of a full examination might sound as follows while being dictated (commands are between < > and in a red font):

On physical examination he was a moderately overweight middle-aged male in no apparent distress. His blood pressure was 135 over 80, heart rate 70 and weight 85 kilograms. <normal head><normal neck> <normal lungs> On cardiac examination his PMI was normally situation and not enlarged. The rhythm was regular and first and second heart sound normal. He had a grade 3 over 6 holosystolic murmur at the apex without radiation. There were no rubs or gallops. <normal abdomen> <normal neuro> <normal skin> His extremities were notable for a trace of ankle edema bilaterally. Pedal pulses were easily palpable bilaterally. <normal neuro>

And what would appear would be the following:

On physical examination he was a moderately overweight middle-aged male in no apparent distress. His blood pressure was 135/80, heart rate 70, and weight 85 kg. Head exam was generally normal. There was no scleral icterus or corneal arcus. Pokemon heartgold rom emuparadise. Mucus membranes were moist. Neck was supple and without jugular venous distension, thyromegally, or carotid bruits. Carotids were easily palpable bilaterally. There was no adenopathy. Lungs were clear to auscultation and percussion, and with normal diaphragmatic excursion. No wheezes or rales were noted. On cardiac examination his PMI was normally situated and not enlarged. The rhythm was regular and first and second heart sounds normal. He had a grade 3/6 holosystolic murmur at the apex without radiation. There were no rubs or gallops. Abdominal exam revealed normal bowel sounds. The abdomen was soft, non-tender, and without masses, organomegally, or appreciable enlargement of the abdominal aorta. Neurologically, the patient was awake, alert, and oriented to person, place and time. There were no obvious focal neurologic abnormalities. Examination of the skin revealed no evidence of significant rashes, suspicious appearing nevi or other concerning lesions.his extremities were notable for a trace of ankle edema bilaterally. Pedal pulses were palpable bilaterally.

These Commands in Detail:

Nuance Dragon Medical

Full Exam:

The patient appeared well nourished and normally developed. Vital signs as documented. Head exam is unremarkable. No scleral icterus of corneal arcus noted. Neck is without jugular venous distension, thyromegally, or carotid bruits. Carotid upstrokes are brisk bilaterally. Lungs clear to auscultation and percussion. Cardiac exam reveals the PMI to be normally sized and situated. Rhythm is regular. First and second hearts sounds normal. No murmurs, rubs or gallops. Abdominal exam reveals normal bowl sounds, no masses, no organomegally and no aortic enlargement. Extremities are non-edematous and both femoral and pedal pulses are normal.

Brief Male Exam:

On exam he appeared in good health and spirits. Vital signs as documented. Skin warm and dry and without overt rashes. Neck without JVD. Lungs clear. Heart exam notable for regular rhythm, normal sounds and absence of murmurs, rubs or gallops. Abdomen unremarkable and without evidence of organomegally, masses, or abdominal aortic enlargement. Extremities non-edematous.

Brief Female Exam:

On exam she appeared in good health and spirits. Vital signs as documented. Skin warm and dry and without overt rashes. Neck without JVD. Lungs clear. Heart exam notable for regular rhythm, normal sounds and absence of murmurs, rubs or gallops. Abdomen unremarkable and without evidence of organomegally, masses, or abdominal aortic enlargement. Extremities non-edematous.

Normal Head:

Head exam was generally normal. There was no scleral icterus or corneal arcus. Mucus membranes were moist.

Normal Neck:

Neck was supple and without jugular venous distension, thyromegally, or carotid bruits. Carotids were easily palpable bilaterally. There was no adenopathy.

Normal Lungs:

Lungs were clear to auscultation and percussion, and with normal diaphragmatic excursion. No wheezes or rales were noted.

Normal Chest:

Examination of the chest was unremarkable. There were no bony deformities, no asymmetry, or other abnormalities.

Normal Post Op Chest:

Examination of the chest was unremarkable. The midline-incision related to this patient's prior heart surgery appeared well healed. There was no sternal instability. No chest wall tenderness was observed.

Normal Heart:

Cardiac exam revealed the PMI to be normally situated and sized. The rhythm was regular and no extrasystoles were noted during several minutes of auscultation. The first and second heart sounds were normal and physiologic splitting of the second heart sound was noted. There were no murmurs, rubs, clicks, or gallops.

Normal Abdomen:

Abdominal exam revealed normal bowel sounds. The abdomen was soft, non-tender, and without masses, organomegally, or appreciable enlargement of the abdominal aorta.

Dragon Naturally Speaking Medical Edition 2

Normal Extremities:

Examination of the extremities revealed easily palpable radial, femoral and pedal pulses. There was no cyanosis, clubbing or edema.

Normal Skin:

Examination of the skin revealed no evidence of significant rashes, suspicious appearing nevi or other concerning lesions.

Normal Neuro:

Dragon Naturally Speaking Medical Transcription

Neurologically, the patient was awake, alert, and oriented to person, place and time. There were no obvious focal neurologic abnormalities.

Although these are simple and easy to create on your own and perhaps better created on the basis of your own typical examination based on your specialty and degree of thoroughness, you may download these files for insertion in your own version of NaturallySpeaking Professional or higher version. Once imported into your copy of Dragon, these may be modified to suit your own purposes.

Dragon Naturally Speaking Medical

Tip: When creating your own text commands to serve as exam snippets, be sure to click 'plain text' on the MyCommands Editor.