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 Physical Exam Template - 5

Description: Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.
(Medical Transcription Sample Report)

GENERAL: Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.
VITAL SIGNS: Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.
HEENT: Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.
NECK: Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.
RESPIRATORY: Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.
CARDIOVASCULAR: Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.
GASTROINTESTINAL: No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.
MUSCULOSKELETAL: Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.
BACK: Nontender on midline. Full range of motion with flexion, extension and sidebending.
SKIN: Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.
LYMPH: Cervical lymph nodes. No lymphadenopathy.
NEUROLOGICAL: Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.
PSYCHIATRIC: Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation.

Keywords: consult - history and phy., respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical,
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