Medical Specialty:
Consult - History and Phy.

Sample Name: Normal Physical Exam Template - 6

Description: Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.
(Medical Transcription Sample Report)

VITAL SIGNS: Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.
CONSTITUTIONAL: Normal appearance for chronological age, does not appear chronically ill.
HEENT: The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear.
NECK: Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes.
RESPIRATORY: Lungs are clear to auscultation bilaterally. The patient has a normal respiratory rate, no signs of consolidation and no egophony. There are no retractions or secondary muscle use. Good bilateral breath sounds are noted.
CARDIOVASCULAR: No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop.
ABDOMEN: Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative.
GENITOURINARY: No bladder tenderness, negative flank pain.
MUSCULOSKELETAL: Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.
NEUROLOGIC: Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal.
HEME/LYMPH: No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.
PSYCHIATRIC: Normal with no overt depression or suicidal ideations.

Keywords: consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,