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Abdominal Pain - Consult Accidental Celesta Ingestion - ER Visit Acute Cystitis & Diabetes Type II Admission History & Physical - Nausea Air Under Diaphragm - Consult Airway Compromise & Foreign Body - ER Visit Anemia - Consult Annual Health Maintenance Exam Ant Bait Exposure - ER Visit Antibiotic Management Consult Antibiotic Therapy Consult Asbestos Exposure - Hemoptysis Atrial Fibrillation - SOAP Blood In Toilet Blood in Urine - ER Visit Breast Calcifications - Preop Consult Burn - Consult Buttock Abscess C. Diff Colitis Consult Care Conference With Family Cellulitis - Discharge Summary Chest Pain & Respiratory Insufficiency Chest Wall Lump - Consult Chronic Abscesses - Discharge Summary Chronic Medical Conditions - Followup Congestion - 21-day-old Congestion & Cough - 5-month-Old Congestion & Fever - 2-month-old Consult - Chest Pain Consult - Chest Pain - 1 Consult - CHF & Lymphedema Consult - Coronary Artery Disease Consult - Hypertension Consult - Sepsis Consult - Stasis Ulcer Consult - Syncope Consult - Vomiting & Nausea COPD & Pneumonia - SOAP Cough & Abdominal Pain Cut on Foot - ER Visit Detox from Heroin Diabetes Mellitus - SOAP Note - 1 Diabetes Mellitus - SOAP Note - 2 Discharge Summary - 1 Discharge Summary - 11 Discharge Summary - 12 Discharge Summary - 13 Discharge Summary - 14 Discharge Summary - 15 Discharge Summary - 16 Discharge Summary - 17 Discharge Summary - 18 Discharge Summary - 19 Discharge Summary - 2 Discharge Summary - 3 Discharge Summary - 4 Discharge Summary - 5 Discharge Summary - 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Discharge Summary Nausea - ER Visit Nausea & Vomiting - ER Visit Normal Child Exam Template Normal ENT Exam Normal ENT Exam - 1 Normal Female Exam Template Normal Female Exam Template - 1 Normal Female Exam Template - 2 Normal Female ROS Template Normal Male Exam Template Normal Male Exam Template - 1 Normal Male Exam Template - 2 Normal Male Exam Template - 3 Normal Male Exam Template - 4 Normal Male ROS Template - 1 Normal Newborn H&P Template Normal Newborn Infant Physical Exam Normal Physical Exam Template Normal Physical Exam Template - 1 Normal Physical Exam Template - 2 Normal Physical Exam Template - 3 Normal Physical Exam Template - 4 Normal Physical Exam Template - 5 Normal Physical Exam Template - 6 Normal Physical Exam Template - 7 Normal ROS Template Normal ROS Template - 1 Normal ROS Template - 2 Normal ROS Template - 3 Normal ROS Template - 4 Normal ROS Template - 5 Not Feeling Well - ER Visit Obesity Hypoventilation Syndrome Pain from Hernia - ER Consult Patient with High Potassium Perioperative Elevated Blood Pressure Pneumoconiosis Pneumonia - Discharge Summary Possible Spider Bite Post Thyroidectomy - Discharge Summary Pressure decubitus Pyelonephritis - Discharge Summary Recurrent Abscesses - Consult Refractory Hypertension - Followup Renal Insufficiency - Consult Request For Consultation Revocation Admission Right Hand Laceration Sepsis - Consult Shortness Of Breath - Progress Note Sleep Apnea Sleep Study Followup Sleepiness - Consult Snoring SOAP - Substance Abuse Thrombocytopenia - Consult Thrombocytopenia - SOAP Note Tongue Swelling Toothache - ER Visit Trouble breathing Trouble Breathing - H&P URI - SOAP Viral Syndrome - ER Visit Weight Loss Evaluation
5013 Samples in 40 Types as on 07/07/2023

Medical Specialty:
General Medicine

Sample Name: Normal Physical Exam Template - 4


Description: Normal physical exam template. Normocephalic. Negative lesions, negative masses.
(Medical Transcription Sample Report)

GENERAL: XXX
VITAL SIGNS: Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.
HEAD: Normocephalic. Negative lesions, negative masses.
EYES: PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.
ENT: Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.
SKIN: Negative rashes, negative masses, negative ulcers. No tattoos.
NECK: Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.
HEART: Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.
LUNGS: Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.
ABDOMEN: Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.
EXTREMITIES: Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.
MUSCULOSKELETAL: Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.
NEUROLOGIC: Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.
GENITOURINARY: Deferred.


See More Samples on General Medicine
Abdominal Pain - Consult Accidental Celesta Ingestion - ER Visit Acute Cystitis & Diabetes Type II Admission History & Physical - Nausea Air Under Diaphragm - Consult Airway Compromise & Foreign Body - ER Visit Anemia - Consult Annual Health Maintenance Exam Ant Bait Exposure - ER Visit Antibiotic Management Consult Antibiotic Therapy Consult Asbestos Exposure - Hemoptysis Atrial Fibrillation - SOAP Blood In Toilet Blood in Urine - ER Visit Breast Calcifications - Preop Consult Burn - Consult Buttock Abscess C. 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Keywords: general medicine, perla, eomi, rashes, ulcers, obstructions negative, negative inflammation, icterus, obstructions, exudates, nasal, palpable, inflammation, masses,