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 - 4

Description: Normal physical exam template. Normocephalic. Negative lesions, negative masses.
(Medical Transcription Sample Report)

GENERAL: XXX
VITAL SIGNS: Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.
HEAD: Normocephalic. Negative lesions, negative masses.
EYES: PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.
ENT: Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.
SKIN: Negative rashes, negative masses, negative ulcers. No tattoos.
NECK: Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.
HEART: Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.
LUNGS: Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.
ABDOMEN: Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.
EXTREMITIES: Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.
MUSCULOSKELETAL: Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.
NEUROLOGIC: Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.
GENITOURINARY: Deferred.


Keywords: consult - history and phy., perla, eomi, rashes, ulcers, obstructions negative, negative inflammation, icterus, obstructions, exudates, nasal, palpable, inflammation, masses,
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