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 Male Exam Template - 1

Description: 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.

Keywords: consult - history and phy., male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx,
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