Sample Type / Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 5
Description: Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.
(Medical Transcription Sample Report)
GENERAL: Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.
VITAL SIGNS: Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.
HEENT: Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.
NECK: Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.
RESPIRATORY: Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.
CARDIOVASCULAR: Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.
GASTROINTESTINAL: No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.
MUSCULOSKELETAL: Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.
BACK: Nontender on midline. Full range of motion with flexion, extension and sidebending.
SKIN: Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.
LYMPH: Cervical lymph nodes. No lymphadenopathy.
NEUROLOGICAL: Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.
PSYCHIATRIC: Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation.
Keywords: office notes, respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical,