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 - 1

Description: An example normal physical exam
(Medical Transcription Sample Report)

GENERAL: Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.

EYES: Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.

ENT: Hearing appears adequate. No obvious asymmetry or deformity of the ears and nose.

NECK: Trachea midline. Symmetric with no obvious deformity or mass; no thyromegaly evident.

RESPIRATORY: The patient has normal and symmetric respiratory effort. Lungs are clear to auscultation.

CARDIOVASCULAR: S1, S2 without significant murmur.

ABDOMEN: Abdomen is flat, soft, nontender. Bowel sounds are active. No masses or pulsations present.

EXTREMITIES: Extremities reveal no remarkable dependent edema or varicosities.

MUSCULOSKELETAL: The patient is ambulatory with normal and symmetric gait. There is adequate range of motion without significant pain or deformity.

SKIN: Essentially clear with no significant rash or lesions. Adequate skin turgor.

NEUROLOGICAL: No acute focal neurologic changes.

PSYCHIATRIC: Mental status, judgment and affect are grossly intact and normal for age.

Keywords: consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam,
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