Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Normal Review of Systems Template Transcription Examples

REVIEW OF SYSTEMS:  No fever, no chills, no weight change. Ocular:  No drainage, no blurred vision. HEENT:  No sore throat, earache, or congestion. No neck pain. COR:  No chest pain. No palpitations. Lungs:  No shortness of breath or cough. GI:  No nausea, no vomiting, no diarrhea, no constipation, no anorexia. GU:  No dysuria, frequency or urgency. No hematuria. No vaginal discharge or vaginal bleeding. Musculoskeletal:  No joint pain or swelling or edema. Skin:  No rash or itching. Psychiatric:  No anxiety, no depression. Endocrine:  No polyuria or polydipsia.

REVIEW OF SYSTEMS:  The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin:  The patient denies itching, rashes, sores and bruises. The patient denies headache, nausea, vomiting, or visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck:  No complaints. Respiratory:  The patient denies shortness of breath, wheeze, cough and hemoptysis. Cardiac:  The patient denies chest pain or palpitation. Gastrointestinal:  The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation, or diarrhea. Urinary:  The patient has normal urination. Musculoskeletal:  The patient denies muscle weakness, pain, or joint stiffness. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  The patient denies recent URI, fever, chills, weight loss or night sweats. No headache, visual symptoms, stiff neck. Had no associated neck, arm, jaw pain or pressure today. Does have chronic back and body aches, which are diffuse and varying in site from day to day. Denies significant abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. No swelling of her hand, feet or face. No neurologic symptoms. No rash. No lymphadenopathy. A 14-point review of systems is otherwise negative.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  No fever. No chills. No dizziness. No weakness.
EYES:  No pain, erythema, or discharge. No blurring of vision.
ENT:  No sore throat, URI symptoms. No epistaxis. No tinnitus.
CARDIOVASCULAR:  No chest pain. No palpitations. No lower extremity edema.
RESPIRATORY:  No shortness of breath, cough, pain with respiration, pleuritic chest pain. No hemoptysis. No dyspnea. No paroxysmal nocturnal dyspnea.
GASTROINTESTINAL:  Normal appetite. No nausea, vomiting, diarrhea. No pain. No bloating. No melena.
GENITOURINARY:  No frequency, urgency, nocturia. No hematuria or dysuria.
MUSCULOSKELETAL:  No arthralgias or myalgias.
INTEGUMENTARY:  No swelling. No bruising. No contusions. No abrasions. No lymphangitis.
NEUROLOGIC:  No headache. No neck pain. No numbness or tingling of the extremities. No weakness.
PSYCHIATRIC:  No confusion.
ENDOCRINE:  No fatigue. No weakness. No history of thyroid, diabetes or adrenal problems.
HEMATOLOGICAL:  No bleeding. No petechiae. No bruising.
ALLERGIES:  No asthma. No urticaria.

REVIEW OF SYSTEMS:  The patient denies any neck, arm, jaw, back, chest pain or pressure symptoms that are new. No palpitations. No dizziness. No sweats. Denies significant headache, visual symptoms, stiff neck. No recent URI, fever, chills, weight loss or night sweats. No abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. Has had no shortness of breath. Denies any swelling of his hands or face or his right lower extremity. No trauma. No skin lesions. No lymphadenopathy. A 14-point review of systems otherwise negative.

REVIEW OF SYSTEMS:  Without fever, chills, weight loss, or night sweats. No URI symptoms, no headache, visual symptoms, stiff neck, no trouble walking, talking, weakness, numbness, tingling of extremities other than the above noted left arm symptoms today. Had no other recent chest pain, pressure. No swelling of his hands, feet, face or symptoms suggestive of CHF. No abdominal pain, change of bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms, testicular pain, ureteral discharge. No rash, no lymphadenopathy. A 14 point review of systems is otherwise negative.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient denies any fever or chills.  HEENT:  No headaches, sore throat.  Positive for left otalgia.  CARDIOVASCULAR:  No history of palpitation or arrhythmia.  RESPIRATORY:  History is negative for cough, productive sputum.  GASTROINTESTINAL:  History is negative for nausea or vomiting.  All other systems essentially negative.

REVIEW OF SYSTEMS:  The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin:  The patient denies itching, rashes, sores and bruises. Head:  The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck:  No complaints. Respiratory:  The patient denies shortness of breath, wheeze, cough or hemoptysis. Cardiac:  The patient denies chest pain or palpitation. Gastrointestinal:  The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary:  The patient has normal urination. The patient has amenorrhea for last 3 years. Musculoskeletal:  The patient denies muscle weakness. The patient denies pain or joint stiffness. The patient denies restriction of range of motion. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  No fevers, chills, lightheadedness, fainting, or weight loss. HEENT:  No visual problems, sore throat, or nasal congestion. CARDIOVASCULAR:  No chest pain, palpitations, or orthopnea. RESPIRATORY:  No cough, shortness of breath or hemoptysis. GASTROINTESTINAL:  See HPI. GENITOURINARY:  No flank pain, dysuria or hematuria. ENDOCRINE:  No polyuria or polydipsia. HEMATOLOGIC:  No bleeding disorder. SKIN:  No rashes or jaundice. All other systems reviewed and are negative.

REVIEW OF SYSTEMS: States she has a headache every day, very dull headache. Does not take anything for it. It only lasts for an hour or two and she is not sure what precipitates the headache. She feels that she does not know how much fluid she takes. Denies any caffeine use and she states these headaches are not new. She has had them for as long as she can remember. No lightheadedness or dizziness. No chest pain or shortness of breath. No cough, wheeze. No fever. No heartburn symptoms. No nausea or vomiting. She is happy with her weight. No constipation. No diarrhea. No genitourinary symptoms. No skin changes, rashes or lesions. Depression: She shrugs her shoulders and states she is not depressed and she denies anxiety. She says she sleeps well at night most of the time.

REVIEW OF SYSTEMS: The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin: The patient denies itching rashes, sores and bruises. The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck: No complaints. Respiratory: The patient denies shortness of breath, wheeze, cough, and hemoptysis. Cardiac: The patient denies chest pain and palpitation. Gastrointestinal: The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary: The patient complains of frequent urination. No blood in urine. No urine retention. No pain during urination. The patient usually goes to the bathroom during the night 2 to 3 times, during the daytime 3 to 4 times. Musculoskeletal: The patient denies muscle weakness. Denies pain, joint stiffness. The patient complains of low back pain radiating to the left lower extremity with numbness of the left lower extremities and episodes of weakness of the left lower extremities. The patient has restriction of range of motion at the lumbosacral spine on flexion and extension. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  Denies weight change, fatigue, weakness, fever, chills, night sweats. Skin: The patient complains of itching, rash on both lower extremities, located on anterior shins. No bruises and no ulceration. The patient denies headache, nausea, vomiting, visual changes. Eye, ears, nose, sinuses, mouth, throat and neck: No complaints. Respiratory: Denies shortness of breath, wheeze, cough, and hemoptysis. Cardiac: Denies chest pain or palpitation. Gastrointestinal: The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary: Has normal urination. Musculoskeletal: Denied muscle weakness. No pain or joint stiffness. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  There is no history of fever, weight loss or cough. CNS:  No history of vision changes, seizure or weakness. ENT:  No history of congestion, postnasal drip, sore throat or hearing changes. Respiratory:  No history of shortness of breath, wheezing or chest pain. Cardiovascular: No history of chest palpitations or arrhythmias. GI:  No history of nausea, vomiting, diarrhea or abdominal pain. GU:  No history of dysuria, frequency or vaginal discharge. Musculoskeletal:  Positive for ankle pain, joint pain, joint edema as well as right lower extremity edema with some tenderness in the calf area.

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