Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Child Exam Template
Normal child physical exam template.
(Medical Transcription Sample Report)
CHILD PHYSICAL EXAMINATION
VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.
GENERAL APPEARANCE: Well.
SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.
HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed.
EYES: Normal with red reflex x2.
EARS: Patent. Normal pinnae, canals, TMs.
NOSE: Patent nares.
MOUTH: No cleft.
NECK: No masses.
CHEST: Normal clavicles.
LUNGS: Clear bilaterally.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel.
GENITALIA: Normal ** genitalia **with testes descended bilaterally.
SPINE: Straight and without deformity.
EXTREMITIES: Equal movements.
MUSCLE TONE: Good.
REFLEXES: Moro, grasp, and suck are normal.
HIPS: No click or clunk.
consult - history and phy., child physical examination, physical, genitalia, child,
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