Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Pediatrics - Neonatal
Sample Name: Normal Newborn Infant Physical Exam

Description: Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.
(Medical Transcription Sample Report)

GENERAL: A well-developed infant in no acute respiratory distress.
VITAL SIGNS: Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.
HEENT: Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.
NECK: Supple without clavicular fracture.
LUNGS: Clear to auscultation.
HEART: Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.
ABDOMEN: Soft with bowel sounds present. No masses or organomegaly.
GENITALIA: Normal.
EXTREMITIES: Without evidence of hip defects.
NEUROLOGIC: The infant has good Moro, grasp, and suck reflexes.
SKIN: Warm and dry without evidence of rash.

Keywords: pediatrics - neonatal, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples