Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 2
Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.
(Medical Transcription Sample Report)
Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.INTEGUMENTARY:
Negative rash, negative jaundice.HEMATOPOIETIC:
Negative bleeding, negative lymph node enlargement, negative bruisability.NEUROLOGIC:
Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.EYES:
Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.EARS:
Negative tinnitus, negative vertigo, negative hearing impairment.NOSE AND THROAT:
Negative postnasal drip, negative sore throat.CARDIOVASCULAR:
Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.RESPIRATORY:
No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.GASTROINTESTINAL:
Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.GENITOURINARY:
Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.MUSCULOSKELETAL:
Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.PSYCHIATRIC:
See psychiatric evaluation.ENDOCRINE:
No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
consult - history and phy., nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,
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.