Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 2

Description: Sample female physical exam.
(Medical Transcription Sample Report)

HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate.
Neck: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no jugular venous distention.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without S3, S4. No murmurs or rubs are appreciated. Peripheral pulses are +2 and equal bilaterally in all four extremities.
Abdomen: Soft, nontender, nondistended with positive bowel sounds. No masses, hepatomegaly or splenomegaly are appreciated.
GU: Reveals normal female external genitalia. Speculum exam reveals vaginal mucosa to be pink and rugous. Cervix appears normal. Bimanual exam reveals uterus to be within normal limits. Adnexa are normal without masses appreciated. There is no cervical motion tenderness.
Rectal Exam: Normal rectal tone. No masses are appreciated. Hemoccult is negative.
Extremities: Reveal no clubbing, cyanosis, or edema.
Joint Exam: Reveals no tenosynovitis.
Integumentary: Normal breast tissue without lumps or masses. There are no skin changes over the breasts. Axillae are free of masses.
Neurologic: Cranial nerves II through XII are grossly intact. Motor strength is 5/5 and equal in all four extremities. Deep tendon reflexes are +2/4 and equal bilaterally. Patient is alert and oriented times 3.
Psychiatric: Grossly normal.
Dermatologic: No lesions or rashes.

Keywords: general medicine, female physical examination, bimanual exam, heent, hemoccult, ii through xii, breast tissue, cardiovascular, dermatologic, external genitalia, integumentary, joint exam, lymphadenopathy, neck, neurologic, physical examination, rectal exam, skin changes, speculum exam, female physical, extremities, masses, oropharynx,
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