Exam Standard ED Exam – © MedTx, LLC 2017

  • EXAM:
    • VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-assess patient):
      • HR:
        • normal HR.
        • tachyardic
      • BP:
        • normotensive.
        • hypertensive
          • (attempted to inform pt to advise to f/u with PMD).
          • hypotensive.
      • O2 sat:
        • no hypoxia
        • hypoxic
      • RR:
        • normal RR
        • tachypnic
    • PHYSICAL EXAM:
      • General:
        • well nourished
        • no distress
        • mild distress
        • moderate distress
        • severe distress
      • HEENT:
        • vision grossly intact.
        • hearing grossly intact.
      • Cardiovascular:
        • no r/m/g
        • no LE swelling
      • Pulmonary:
        • Lungs CBTA,
        • No respiratory distress,
        • Speaking comfortably in full sentences.
        • I/E wheezing,
        • rales,
        • rhonchi
        • respiratory distress,
      • GI:
        • abd soft,
        • abd non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ
        • TTP in RLQ
      • Neuro:
        • Normal LOC.
        • No grossly focal neurological deficits.
        • Somnolent through protecting airway
      • MSK:
        • no deformities,
        • moving all extremities
        • Non-ambulatory.
      • Psych:
        • Normal speech.
        • Demonstrates linear thinking.
        • No SI/HI.
        • Endorses SI
        • Endorses HI
        • Exam consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.

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