Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 2
Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.
(Medical Transcription Sample Report)
This is a well-developed and well-nourished, ??VITAL SIGNS:
Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.HEAD, EYES, EARS, NOSE AND THROAT:
The pupils were equal, round and reactive to light. Extraocular movements are intact. Sclera are nonicteric. Ears, nose, mouth and throat - Externally the ears and nose are normal. The mucous membranes are moist and midline.NECK:
The neck is supple without masses. No thyromegaly, no carotid bruits, no adenopathy.LUNGS:
There is a normal respiratory effort. Bilateral breath sounds are clear. No wheezes or rales or rhonchi.CARDIAC:
Normal cardiac impulse location. S1 and S2 are normal. No rubs, murmurs or gallops. A regular rate and rhythm. There are no abdominal aortic bruits. The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.EXTREMITIES:
The extremities are without clubbing, cyanosis, or edema.CHEST:
The chest examination is unremarkable.BREASTS:
The breasts show no masses or tenderness. No axillary adenopathy.ABDOMEN:
The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.RECTAL:
Examination was deferred.LYMPHATIC:
No neck, axillary or groin adenopathy was noted.SKIN EXAMINATION:
The cranial nerves two through twelve are grossly intact. Patellar and biceps reflexes are normal.PSYCHIATRIC:
The patient is awake, alert and oriented times three. Judgment and insight are good. Affect is appropriate.
consult - history and phy., vital signs, head, eyes, ears, nose, throat, neck, lungs, cardiac, physical exam, extraocular movements, adenopathy, examination,
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