Sample Type / Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template
An example of a physical exam
(Medical Transcription Sample Report)
Alert, well developed, in no acute distress.MENTAL STATUS:
Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.EYES:
Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.EAR, NOSE AND THROAT:
Oropharynx clean, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. No lymph node swelling or tenderness.RESPIRATORY:
Clear to auscultation and percussion. No wheezing, rales or rhonchi.CARDIOVASCULAR:
Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.GASTROINTESTINAL:
Abdomen soft, nondistended. No pulsatile mass, no flank tenderness or suprapubic tenderness. No hepatosplenomegaly.NEUROLOGIC:
Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Babinski negative. Moves all extremities spontaneously. Sensation intact bilaterally.SKIN:
No rashes or lesions. No petechia. No purpura. Good turgor. No edema.MUSCULOSKELETAL:
No cyanosis or clubbing. No gross deformities. Capable of free range of motion without pain or crepitation. No laxity, instability or dislocation.BONE:
No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.MUSCLE:
No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.LYMPHATIC:
Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes.
office notes, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam,
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