Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 6
Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.
(Medical Transcription Sample Report)
Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.CONSTITUTIONAL:
Normal appearance for chronological age, does not appear chronically ill.HEENT:
The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear.NECK:
Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes.RESPIRATORY:
Lungs are clear to auscultation bilaterally. The patient has a normal respiratory rate, no signs of consolidation and no egophony. There are no retractions or secondary muscle use. Good bilateral breath sounds are noted.CARDIOVASCULAR:
No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop.ABDOMEN:
Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative.GENITOURINARY:
No bladder tenderness, negative flank pain.MUSCULOSKELETAL:
Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.NEUROLOGIC:
Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal.HEME/LYMPH:
No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.PSYCHIATRIC:
Normal with no overt depression or suicidal ideations.
consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,
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