Medical Specialty:
General Medicine

Sample Name: Normal Physical Exam Template - 2


Description: Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.
(Medical Transcription Sample Report)


GENERAL APPEARANCE: This is a well-developed and well-nourished, ??
VITAL SIGNS: Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.
HEAD, EYES, EARS, NOSE AND THROAT: The pupils were equal, round and reactive to light. Extraocular movements are intact. Sclera are nonicteric. Ears, nose, mouth and throat - Externally the ears and nose are normal. The mucous membranes are moist and midline.
NECK: The neck is supple without masses. No thyromegaly, no carotid bruits, no adenopathy.
LUNGS: There is a normal respiratory effort. Bilateral breath sounds are clear. No wheezes or rales or rhonchi.
CARDIAC: Normal cardiac impulse location. S1 and S2 are normal. No rubs, murmurs or gallops. A regular rate and rhythm. There are no abdominal aortic bruits. The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.
EXTREMITIES: The extremities are without clubbing, cyanosis, or edema.
CHEST: The chest examination is unremarkable.
BREASTS: The breasts show no masses or tenderness. No axillary adenopathy.
ABDOMEN: The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.
RECTAL: Examination was deferred.
LYMPHATIC: No neck, axillary or groin adenopathy was noted.
SKIN EXAMINATION: Unremarkable.
MUSCULOSKELETAL EXAMINATION: Grossly normal.
NEUROLOGIC: The cranial nerves two through twelve are grossly intact. Patellar and biceps reflexes are normal.
PSYCHIATRIC: The patient is awake, alert and oriented times three. Judgment and insight are good. Affect is appropriate.

Keywords: general medicine, vital signs, head, eyes, ears, nose, throat, neck, lungs, cardiac, physical exam, extraocular movements, adenopathy, examination,