Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Female Exam Template
Sample/template for a normal female multisystem exam
(Medical Transcription Sample Report)
The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.EYES:
The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.EARS, NOSE AND THROAT:
The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.NECK:
The neck was supple. The thyroid gland was not enlarged by palpation.RESPIRATORY:
The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.CARDIOVASCULAR:
Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.BREASTS:
Breast inspection showed them to be symmetrical with no nipple discharge. Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.GASTROINTESTINAL:
The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.GU:
The external genitalia appeared to be normal. The pelvic exam revealed no adnexal masses. The uterus appeared to be normal in size and there was no cervical motion tenderness.LYMPHATIC:
There was no appreciated node that I could feel in the groin or neck area.MUSCULOSKELETAL:
The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.SKIN:
Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.NEUROLOGIC:
Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.PSYCHIATRIC:
The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.
consult - history and phy., eyes, constitutional, within normal limits, tongue, multisystem, heart, ears, nose, respiratory, extremities, breasts, oropharynx, neck,
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