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)

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.

Keywords: general medicine, perla, eomi, rashes, ulcers, obstructions negative, negative inflammation, icterus, obstructions, exudates, nasal, palpable, inflammation, masses,