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Normal Physical Exam Template Transcription Examples / Samples

VITAL SIGNS:  Blood pressure 126/76, pulse 66, weight 180, O2 saturation 99% on room air.
GENERAL:  The patient is alert, oriented, pleasant and friendly. Does not seem anxious or depressed. In no acute physical distress.
HEENT:  NCAT. Pupils are equal, round and reactive. EOMs are intact. No temporal bruits. TMs are gray, nonbulging. No TMJ crepitus. Oropharynx is benign. Dentition intact.
NECK:  Supple without lymphadenopathy or thyromegaly. C-spine range of motion intact. Mild tenderness over the cervical muscles and trapezia bilaterally.
CHEST:  Lung sounds are clear to auscultation. Normal respiratory effort. No rales, wheezes or rhonchi.
CARDIOVASCULAR:  Regular rate and rhythm. S1, S2. No S3, S4 or murmur.
ABDOMEN:  Soft and nontender without guarding, rebound, masses or rigidity. Bowel sounds are normoactive.
GENITOURINARY:  Normal external genitalia. No masses palpated. No hernias.
MUSCULOSKELETAL:  Normal bulk and tone. Gait:  Steady and even. Range of motion of the upper and lower extremities intact and symmetric. Range of motion of the shoulders and neck intact with mild tenderness over the cervical muscles and trapezia as noted above.
NEUROLOGICAL:  No focal deficits. DTRs equal and symmetric. Cranial nerves intact.
SKIN:  Warm and dry. No rashes or suspicious lesions.

GENERAL:  The patient is a healthy-appearing, somewhat overweight male, in no acute distress.
VITAL SIGNS:  Blood pressure 124/68 in the right arm, in a sitting position, with heart rate of 66, equal in both radial pulses; respiratory rate of 16. Height 64 inches and weight 180 pounds.
SKIN:  Normal. There are no abnormal pigmented lesions, signs of basal or squamous cell carcinomas. No rashes.
HEENT:  Atraumatic, normocephalic. Tympanic membranes are normal. Weber is midline. Conjunctivae and sclerae are clear. Extraocular movements are full. Pupils are equal, 3/3, round and reactive to light. Funduscopic exam is normal. Nasal and oral mucosa normal. Pharynx is negative.
NECK:  Supple. There is no lymphadenopathy. No masses are noted. Carotids are 2/2 without bruits. Trachea is midline. Thyroid is normal.
LUNGS:  Clear to percussion and auscultation.
Pulses in the radial, brachial, carotid, femoral, dorsalis pedis are 2/2 without bruits. There is no adenopathy in the epitrochlear, cervical, supraclavicular, infraclavicular, axillary or inguinal areas.
BREASTS:  Without masses, dimpling, discharge or erythema.
CARDIOVASCULAR:  Without murmurs or gallops.
ABDOMEN:  Normal bowel sounds. No organomegaly. No masses. No tenderness.
GENITOURINARY:  The patient is an uncircumcised male. Testes are descended. No masses are noted.
RECTAL:  Exam is normal. Prostate is not enlarged.
NEUROLOGICAL:  Alert and oriented. Cranial nerves II through XII are intact. Motor and sensory exams are normal. Motor and sensory reflexes are 2+ and symmetric with bilateral plantar responses.

VITAL SIGNS:  Blood pressure 124/88. Pulse 94 and regular. Height self-reported as 6 feet. Weight 180 pounds.
GENERAL APPEARANCE:  The patient is a pleasant gentleman, in no acute distress.
HEENT:  Normocephalic, atraumatic. Pupils equally round and reactive to light. Oropharynx clear. Tympanic membranes normal bilaterally. Does have a small amount of cerumen in the right external auditory canal.
NECK:  No lymphadenopathy, no thyromegaly, no carotid bruits. Does have some limitation with lateral rotation and there is crepitus with flexion and extension of the neck.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Irregularly irregular with no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended, with normal bowel sounds. No organomegaly, no masses.
RECTAL:  Mildly enlarged prostate, symmetric, firm and without evidence of mass or nodule.
EXTREMITIES:  No clubbing, cyanosis or edema, +2 patellar reflexes bilaterally. Examination of the left shoulder reveals positive Hawkins and Neer impingement signs. Does also have some mild posterior shoulder joint tenderness. No swelling. Appears to have intact supraspinatus strength but testing is very limited. Does have mildly impaired internal rotation of the shoulder. The right shoulder has a positive Neer impingement sign, but negative Hawkins impingement sign and has a fairly good range of motion at that shoulder with no joint tenderness or swelling.

PHYSICAL EXAMINATION:  Today, blood pressure was 114/74. Pulse was 82. Respiratory rate was 18. A pleasant woman in no acute distress. Neck was supple, no bruits. Negative Lhermitte sign. Cardiovascular:  Regular rhythm. She does have a mild left sternal border murmur. Extremities:  No edema was noted. Neurological:  She was alert. She was oriented x3. She was able to register 3 words immediately and was able to recall 1 out of 3 after 3 minutes. She was able to name the months of the year forwards and backwards without any difficulty. Her speech was somewhat hesitant, however, no paraphasic errors. She was able to copy an abstract figure and was able to draw a clock and place the hands correctly at 10 past 11. On cranial nerve examination, her pupils were about 3 mm, both reactive to light. I did not see any afferent defect. Her right disk was normal; her left disk, was not able to see the presence of a cataract. Her extraocular movements were intact with no nystagmus. Facial sensation and strength were normal. Normal hearing bilaterally. Palate and uvula elevate well and symmetrical. Normal shoulder shrug. Tongue was midline. Motor strength was 5/5 throughout, except for finger extensors that were 4/5 on the right, 5-/ 5 on the left; interossei 4/5 on the right, 5-/ 5 on the left. She had a right pronator drift. Motor strength in her lower extremity was overall quite good. However, she has some decreased velocity of movement on finger tapping and foot tapping bilaterally, right worse than left. She has mild spasticity on her right arm and leg, has postural tremors in both hands. Presence of mild dysmetria on finger-to-nose and heel-to-shin bilaterally. She had decreased pinprick in her right arm and leg. Decreased vibration in toes. Some decreased position sense on her right toe, normal on the left. Her deep tendon reflexes were +3 in the upper extremities, but left was worse than right; +1 in the lower extremities with bilateral upgoing toes. I did not notice any clonus. Her gait was wide-based, a little bit spastic on the right. She was not able to do tandem gait and had a positive Romberg.