Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template

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


GENERAL: Alert, well developed, in no acute distress.

MENTAL STATUS: Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.

EYES: Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.

EAR, NOSE AND THROAT: Oropharynx clean, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. No lymph node swelling or tenderness.

RESPIRATORY: Clear to auscultation and percussion. No wheezing, rales or rhonchi.

CARDIOVASCULAR: Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.

GASTROINTESTINAL: Abdomen soft, nondistended. No pulsatile mass, no flank tenderness or suprapubic tenderness. No hepatosplenomegaly.

NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Babinski negative. Moves all extremities spontaneously. Sensation intact bilaterally.

SKIN: No rashes or lesions. No petechia. No purpura. Good turgor. No edema.

MUSCULOSKELETAL: No cyanosis or clubbing. No gross deformities. Capable of free range of motion without pain or crepitation. No laxity, instability or dislocation.

BONE: No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.

MUSCLE: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.

LYMPHATIC: Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes.

Keywords: general medicine, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam,