Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 3

Description: Normal physical exam template. Well developed, well nourished, in no acute distress.
(Medical Transcription Sample Report)

PHYSICAL EXAMINATION

GENERAL APPEARANCE: Well developed, well nourished, in no acute distress.
VITAL SIGNS: ***
SKIN: Inspection of the skin reveals no rashes, ulcerations or petechiae.
HEENT: The sclerae were anicteric and conjunctivae were pink and moist. Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. External inspection of the ears and nose showed no scars, lesions, or masses. Lips, teeth, and gums showed normal mucosa. The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.
NECK: Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt.
CHEST: Normal AP diameter and normal contour without any kyphoscoliosis.
LUNGS: Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.
CARDIOVASCULAR: There was a regular rate and rhythm without any murmurs, gallops, rubs. The carotid pulses were normal and 2+ bilaterally without bruits. Peripheral pulses were 2+ and symmetric.
ABDOMEN: Soft and nontender with normal bowel sounds. The liver span was approximately 5-6 cm in the right midclavicular line by percussion. The liver edge was nontender. The spleen was not palpable. There were no inguinal or umbilical hernias noted. No ascites was noted.
RECTAL: Normal perineal exam. Sphincter tone was normal. There was no external hemorrhoids or rectal masses. Stool Hemoccult was negative. The prostate was normal size without any nodules appreciated (men only).
LYMPH NODES: No lymphadenopathy was appreciated in the neck, axillae or groin.
MUSCULOSKELETAL: Gait was normal. There was no tenderness or effusions noted. Muscle strength and tone were normal.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Alert and oriented x 3. Normal affect. Gait was normal. Normal deep tendon reflexes with no pathological reflexes. Sensation to touch was normal.

Keywords: consult - history and phy., well developed, well nourished, in no acute distress, normal physical exam, nontender, liver, rectal, tone, appreciated, gait, physical, masses, 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