Normal Physical Examination Template Format For Medical Transcriptionists

PHYSICAL EXAM TEMPLATE FORMAT # 1:

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is alert, oriented and has a bandage over his left eye. He is in no acute distress.
VITAL SIGNS: T-max was 100, currently 97.5, blood pressure 110/60, respirations 22, and heart rate 88.
HEENT: Head is normocephalic. He does have an area of purpura over his left periorbital area. There is also a small laceration over his forehead. The sinuses are otherwise nontender. Pupils are equal and reactive. The nares are patent. Oropharynx reveals poor dentition but is clear without lesions.
NECK: Supple without lymphadenopathy.
HEART: Regular rate and rhythm.
LUNGS: Revealed decreased breath sounds at the bases. No crackles or wheezes are heard.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds heard. Inguinal area is normal.
EXTREMITIES: Without cyanosis, clubbing or edema.
NEUROLOGICAL: Gross nonfocal. Skin: Warm and dry without any rash. There is no costovertebral angle tenderness.

PE TEMPLATE FORMAT # 2:

PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is alert and oriented and in no acute distress. VITALS SIGNS: Temperature 98.4, pulse 72, respirations 20, and blood pressure is 118/76. HEENT: Head is normocephalic with normal hair distribution. No evidence of trauma. Ears: No acute purulent discharge. Eyes: Conjunctivae pink with no scleral jaundice. Nose: Normal mucosa and septum. NECK: Supple with no cervical or supraclavicular lymphadenopathy. Trachea is midline. Thyroid: Not palpable. LUNGS: Normal symmetrical expansion of both hemithoraces. Coarse breath sounds with some rhonchi. HEART: S1 and S2 normal. ABDOMEN: Soft. EXTREMITIES: No swelling or effusion in any of the joints of the hands or feet. No peripheral edema. SKIN: Normal color, turgor and temperature. No ulcerations or rashes noted. LYMPHATICS: No cervical or supraclavicular lymphadenopathy. NEUROLOGICAL: Cannot be assessed at this time since the patient is intubated and sedated.

OBJECTIVE: VITAL SIGNS: In the last 24 hours, maximum temperature was 97.8, pulse 70, respirations 20, and blood pressure 116/64. HEENT: Normal. LUNGS: Clear bilaterally. No wheezing. No crackles. CARDIAC: S1, S2 audible. The patient has a loud systolic ejection murmur. No peripheral edema. ABDOMEN: Normal. No organomegaly. Normoactive bowel sounds. NEUROLOGICAL: Alert and oriented. GCS is 15.

PE TEMPLATE FORMAT # 3:

PHYSICAL EXAMINATION: General Appearance: This is a (XX)-year-old female, who answers questions appropriately and currently is in no apparent distress. Vital Signs: Her blood pressure is 142/74, heart rate is 72, respiratory rate is 22, saturation 98% on room air, currently afebrile, temperature 98.2. Skin: Warm and dry without exanthem. HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular movements are intact. Oral mucosa is moist. There is no obvious bleeding in the gum. Oropharynx is without erythema or exudate. Lungs: Breath sounds are clear bilaterally without rales, rhonchi or wheezing. Heart: No elevation of JVP. Heart is irregularly irregular with no appreciable gallops, rubs, murmurs or extra heart sounds. Abdomen: Soft, nontender, nondistended in all quadrants. No audible bowel sounds. No palpable masses. Peripheral Vascular: Radial and pedal pulses are 2/4 bilaterally. Extremities: Warm without clubbing, edema or cyanosis. Neurological: The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric.

PHYSICAL EXAMINATION: Vital Signs: Temperature 100.2, pulse 94, respirations 21 and blood pressure 112/66. General: A well-developed, well-nourished male with pleasant affect. HEENT: Normocephalic and atraumatic. Extraocular movements full. Sclerae anicteric. Neck: Supple. Free of masses or thyromegaly. No carotid bruits. Lungs: Clear. Symmetrically expanding. Cardiac: Rhythm is sinus. No murmurs or gallops. Abdomen: Obese, soft with obvious inflammation focused within the right subumbilical area. Scattered healed maculopapular ulcerations are distributed along the subumbilical transverse belt line. Surrounding one of the ulcerations, right infraumbilical region, is significant edema and erythema, which expands in a band-like distribution along the belt line across the right lateral abdomen to the midaxillary line level. Early fluctuance is developing around the epicenter of the inflammation, and there is some minor purulent drainage therefrom. No intraabdominal masses, hepatic or splenic enlargement. No peritoneal signs are present. Neurologic: No focal deficits.

OBJECTIVE: The patient is a (XX)-year-old lady who is awake, alert, oriented, and in no acute distress. Chest is clear. Heart is regular. The right eyelid is closed; she is able to open it. Both pupils are equal, reactive to light and accommodation. There appears to be no overt nystagmus with the exception of perhaps a mild tap on the left and leftward gaze in the left eye. Both TMs and canals are occluded with cerumen. The patient’s vitals are also noted. Her blood pressure is on the low side at 100/72.

PE TEMPLATE FORMAT # 4:

PHYSICAL EXAMINATION:

GENERAL: The patient is a well-developed, well-nourished male in no apparent distress. He is alert and oriented x3.

VITAL SIGNS: Temperature 98.4, pulse 72, respirations 18, blood pressure 146/78, and O2 saturation 96% on room air.

HEENT: Head is normocephalic and atraumatic. Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Nares appeared normal. Mouth is well hydrated and without lesions. Mucous membranes are moist. Posterior pharynx clear of any exudate or lesions.

NECK: Supple. No carotid bruits. No lymphadenopathy or thyromegaly.

LUNGS: Clear to auscultation.

HEART: Regular rate and rhythm without murmur.

ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. No hepatosplenomegaly was noted.

EXTREMITIES: Without any cyanosis, clubbing, rash, lesions or edema.

NEUROLOGIC: Cranial nerves II through XII are grossly intact.

PSYCHIATRIC: Flat affect, but denies suicidal or homicidal ideations.

SKIN: No ulceration or induration present.

PHYSICAL EXAMINATION:
VITAL SIGNS: The patient was afebrile. Temperature 98.4 degrees. Pulse noted to range from as low as 36 beats per minute to above 62 beats per minute. Respiratory rate 18. Blood pressure 136/64 without any orthostatic changes.
GENERAL: The patient appeared to be in no distress. He was lying in bed comfortably.
SKIN: There were fading ecchymotic lesions on thighs and arms.
HEENT: Head was atraumatic and normocephalic. Eyes: Extraocular muscles were intact. The patient was anicteric. Pupils were equally reactive to light. Ears: There were no lesions. Nose: No lesions were noted. Throat: There was no thrush, no exudate, no erythema. There was no evidence of gum bleeding.
NECK: Supple. There was no JVD. No bruit was heard over the carotids.
CHEST: There was a well-healed midline scar without any tenderness to the chest wall.
BREASTS: There was no gynecomastia.
HEART: S1 and S2, irregular. S1 was soft in the mitral area, and there was a systolic murmur of about 3/6 in the left sternal border.
LUNGS: Air entry was good. There were slight basilar crackles, left more than right.
ABDOMEN: Obese, soft and nontender. Bowel sounds were present.
RECTAL: Stool guaiacs were negative. There were no masses in the rectum.
MUSCULOSKELETAL: There was no deformity. There was full range of motion in all the extremities. There was no edema.
NEUROLOGICAL: There was no focal deficit. Cranial nerves II through XII were intact.

PHYSICAL EXAMINATION:
GENERAL: The patient is walking around in the room. Her blood pressure was 142/72, pulse is 78, respirations 20, and temperature is 97.4.
HEENT: Normocephalic, atraumatic. Extraocular movements intact. No sinus tenderness. Oropharynx clear. Mucous membranes are moist.
NECK: Supple without lymph node.
CHEST: Clear and good breath sounds equally. No wheezing. No rhonchi.
HEART: S1, S2. Regular rate and rhythm.
ABDOMEN: Soft, nontender. No organomegaly.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: She is alert and oriented x3. No focal deficit. No sensory deficit.
PSYCHOSOCIAL: She is in a good mood. No signs of depression and is nonfocal.
INTEGUMENT: Moist mucous membranes. Good skin turgor, intact.

PHYSICAL EXAMINATION:
GENERAL: The patient is lying comfortably in bed. She is surrounded by her family members. She looks pretty comfortable.
HEENT: Normocephalic, atraumatic. Extraocular movement intact. No conjunctival pallor. No sinus tenderness. Oropharynx is clear.
NECK: Supple without lymph node.
HEART: S1, S2. Irregular rate and tachycardia.
CHEST: Decreased breath sounds at both bases.
EXTREMITIES: Left extremity is in a sling. The surgery site looks inflamed and erythematous. There is some yellowish discharge from the lower part of the incision site. No pedal edema.
CENTRAL NERVOUS SYSTEM: Awake, alert, and oriented. No sensory deficit. Could not check the motor on the left side, secondary to surgery, but otherwise negative. Cranial nerves II-XII intact.
PSYCHOSOCIAL: The patient’s family is visiting her. They appear to be very involved in her care. No acute changes.