Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 4
Normal physical exam template. Normocephalic. Negative lesions, negative masses.
(Medical Transcription Sample Report)
Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.HEAD:
Normocephalic. Negative lesions, negative masses.EYES:
PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.ENT:
Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.SKIN:
Negative rashes, negative masses, negative ulcers. No tattoos.NECK:
Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.HEART:
Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.LUNGS:
Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.ABDOMEN:
Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.EXTREMITIES:
Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.MUSCULOSKELETAL:
Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.NEUROLOGIC:
Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.GENITOURINARY:
consult - history and phy., perla, eomi, rashes, ulcers, obstructions negative, negative inflammation, icterus, obstructions, exudates, nasal, palpable, inflammation, masses,
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