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 Child Exam Template

Description: Normal child physical exam template.
(Medical Transcription Sample Report)

CHILD PHYSICAL EXAMINATION

VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.
GENERAL APPEARANCE: Well.
BREATHING: Unlabored.
SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.
HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed.
EYES: Normal with red reflex x2.
EARS: Patent. Normal pinnae, canals, TMs.
NOSE: Patent nares.
MOUTH: No cleft.
THROAT: Clear.
NECK: No masses.
CHEST: Normal clavicles.
LUNGS: Clear bilaterally.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel.
GENITALIA: Normal ** genitalia **with testes descended bilaterally.
ANUS: Patent.
SPINE: Straight and without deformity.
EXTREMITIES: Equal movements.
MUSCLE TONE: Good.
REFLEXES: Moro, grasp, and suck are normal.
HIPS: No click or clunk.

Keywords: pediatrics - neonatal, child physical examination, physical, genitalia, child,
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