Sample Type / Medical Specialty: Consult - History and Phy.
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.
consult - history and phy., mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam,
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