Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 1
An example/template for a routine normal male physical exam.
(Medical Transcription Sample Report)
MALE PHYSICAL EXAMINATION
HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate.
NECK: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no jugular venous distention.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm without S3, S4. No murmurs or rubs are appreciated.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. No masses, hepatomegaly or splenomegaly are appreciated.
GU: Normal **circumcised male. No discharge or hernias. No testicular masses.
RECTAL EXAM: Normal rectal tone. Prostate is smooth and not enlarged. Stool is Hemoccult negative.
EXTREMITIES: Reveal no clubbing, cyanosis, or edema. Peripheral pulses are +2 and equal bilaterally in all four extremities.
JOINT EXAM: Reveals no tenosynovitis.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Motor strength is 5/5 and equal in all four extremities. Deep tendon reflexes are +2/4 and equal bilaterally. Patient is alert and oriented times 3.
PSYCHIATRIC: Grossly normal.
DERMATOLOGIC: No lesions or rashes.
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