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 Female Exam Template - 2

Description: An example/template for a routine normal female physical exam.
(Medical Transcription Sample Report)

VITAL SIGNS: Blood pressure *, pulse *, respirations *, temperature *.
GENERAL APPEARANCE: Alert and in no apparent distress, calm, cooperative, and communicative.
HEENT: Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. Ears: Normal set, shape, TMs, canals and hearing. Nose and Sinuses: Negative. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.
NECK: Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.
CHEST: Lungs are bilaterally clear to auscultation and percussion.
HEART: S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI nondisplaced. Chest wall unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected.
BREASTS: In the seated and supine position unremarkable.
ABDOMEN: No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and no intraabdominal bruit auscultated.
RECTAL: Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.
EXTREMITIES: Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints.
BACK: Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs.
NEUROLOGIC: Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable.
SKIN: Unremarkable for any premalignant or malignant condition with normal changes for age.

Keywords: consult - history and phy., heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,
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