Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 2

Description: Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.
(Medical Transcription Sample Report)

GENERAL APPEARANCE: This is a well-developed and well-nourished, ??
VITAL SIGNS: Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.
HEAD, EYES, EARS, NOSE AND THROAT: The pupils were equal, round and reactive to light. Extraocular movements are intact. Sclera are nonicteric. Ears, nose, mouth and throat - Externally the ears and nose are normal. The mucous membranes are moist and midline.
NECK: The neck is supple without masses. No thyromegaly, no carotid bruits, no adenopathy.
LUNGS: There is a normal respiratory effort. Bilateral breath sounds are clear. No wheezes or rales or rhonchi.
CARDIAC: Normal cardiac impulse location. S1 and S2 are normal. No rubs, murmurs or gallops. A regular rate and rhythm. There are no abdominal aortic bruits. The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.
EXTREMITIES: The extremities are without clubbing, cyanosis, or edema.
CHEST: The chest examination is unremarkable.
BREASTS: The breasts show no masses or tenderness. No axillary adenopathy.
ABDOMEN: The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.
RECTAL: Examination was deferred.
LYMPHATIC: No neck, axillary or groin adenopathy was noted.
SKIN EXAMINATION: Unremarkable.
MUSCULOSKELETAL EXAMINATION: Grossly normal.
NEUROLOGIC: The cranial nerves two through twelve are grossly intact. Patellar and biceps reflexes are normal.
PSYCHIATRIC: The patient is awake, alert and oriented times three. Judgment and insight are good. Affect is appropriate.

Keywords: office notes, vital signs, head, eyes, ears, nose, throat, neck, lungs, cardiac, physical exam, extraocular movements, adenopathy, examination,
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