Sample Name: Normal Male Exam Template
Description: Sample/template for a normal male multisystem exam.
(Medical Transcription Sample Report)
CONSTITUTIONAL: The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.
EYES: The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.
EARS, NOSE AND THROAT: The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.
NECK: The neck was supple. The thyroid gland was not enlarged by palpation.
RESPIRATORY: The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.
CARDIOVASCULAR: Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.
GASTROINTESTINAL: The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.
GU: The scrotal elements were normal. The testes were without discrete mass. The penis showed no lesion, no discharge.
LYMPHATIC: There was no appreciated node that I could feel in the groin or neck area.
SKIN: Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.
NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.
PSYCHIATRIC: The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.
Keywords: office notes, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,