Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 2
Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.
(Medical Transcription Sample Report)
This is a well-developed and well-nourished, ??VITAL SIGNS:
Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.HEAD, EYES, EARS, NOSE AND THROAT:
The pupils were equal, round and reactive to light. Extraocular movements are intact. Sclera are nonicteric. Ears, nose, mouth and throat - Externally the ears and nose are normal. The mucous membranes are moist and midline.NECK:
The neck is supple without masses. No thyromegaly, no carotid bruits, no adenopathy.LUNGS:
There is a normal respiratory effort. Bilateral breath sounds are clear. No wheezes or rales or rhonchi.CARDIAC:
Normal cardiac impulse location. S1 and S2 are normal. No rubs, murmurs or gallops. A regular rate and rhythm. There are no abdominal aortic bruits. The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.EXTREMITIES:
The extremities are without clubbing, cyanosis, or edema.CHEST:
The chest examination is unremarkable.BREASTS:
The breasts show no masses or tenderness. No axillary adenopathy.ABDOMEN:
The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.RECTAL:
Examination was deferred.LYMPHATIC:
No neck, axillary or groin adenopathy was noted.SKIN EXAMINATION:
The cranial nerves two through twelve are grossly intact. Patellar and biceps reflexes are normal.PSYCHIATRIC:
The patient is awake, alert and oriented times three. Judgment and insight are good. Affect is appropriate.
general medicine, vital signs, head, eyes, ears, nose, throat, neck, lungs, cardiac, physical exam, extraocular movements, adenopathy, examination,
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