Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 1
An example normal physical exam
(Medical Transcription Sample Report)
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.
consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam,
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