Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine
Sample Name: Female Exam & ROS

Description: Sample female exam and review of systems.
(Medical Transcription Sample Report)

GENERAL REVIEW OF SYSTEMS
General: No fevers, chills, or sweats. No weight loss or weight gain.
Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.
Neurologic: No paresis, paresthesias, or syncope.
Eyes: No double vision or blurred vision.
Ears: No tinnitus or decreased auditory acuity.
ENT: No allergy symptoms, such as rhinorrhea or sneezing.
GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.
GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.
Psych: No symptoms of depression or anxiety.
Pulmonary: No wheezing, cough, or sputum production.
Skin: No skin lesions or nonhealing lesions.
Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.
Endocrine: No heat or cold intolerance. No polydipsia.
Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.

PHYSICAL EXAM
Vitals: Blood pressure today was *, heart rate *, respiratory rate *.
Ears: TMs intact bilaterally. Throat is clear without hyperemia.
Mouth: Mucous membranes normal. Tongue normal.
Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.
Chest: Clear to auscultation; no dullness to percussion.
Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.
Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.
Extremities: Bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.
Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.
Breasts: Bilaterally symmetrical without tenderness, masses. No axillary tenderness or masses.
Pelvic examination: Revealed normal external genitalia. Pap smear obtained without difficulty. Bimanual examination revealed no pelvic tenderness or masses. No uterine enlargement. Rectal examination revealed normal sphincter tone, no rectal masses. Stool is Hemoccult negative.

Keywords: general medicine, female exam, extremities, hemoccult, musculoskeletal, neurologic examination, pelvic examination, back pain, bone pain, chills, cough, cranial nerves ii through xii, fevers, heart rate, joint pain, paresis, paresthesias, polydipsia, regular rhythm, weight gain, wheezing, examination revealed, pelvic, rectal, heartburn, symmetrical, tenderness, indigestion, 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