Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 1

Description: An example normal physical exam
(Medical Transcription Sample Report)


GENERAL: 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.

Keywords: consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam,