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 - 6

Description: Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.
(Medical Transcription Sample Report)

VITAL SIGNS: Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.
CONSTITUTIONAL: Normal appearance for chronological age, does not appear chronically ill.
HEENT: The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear.
NECK: Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes.
RESPIRATORY: Lungs are clear to auscultation bilaterally. The patient has a normal respiratory rate, no signs of consolidation and no egophony. There are no retractions or secondary muscle use. Good bilateral breath sounds are noted.
CARDIOVASCULAR: No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop.
ABDOMEN: Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative.
GENITOURINARY: No bladder tenderness, negative flank pain.
MUSCULOSKELETAL: Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.
NEUROLOGIC: Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal.
HEME/LYMPH: No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.
PSYCHIATRIC: Normal with no overt depression or suicidal ideations.

Keywords: office notes, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,
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