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 hypoxiahypoxic RR: normal RRtachypnic  PHYSICAL EXAM: General: well nourishedno distressmild distressmoderate distresssevere 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,rhonchirespiratory distress, GI: abd soft, abd non-tender in all 4 quadrants,TTP diffuselyTTP in RUQTTP in RLQ Neuro: Normal LOC. No grossly focal neurological deficits.Somnolent through protecting airway MSK: no deformities, moving all extremitiesNon-ambulatory. Psych: Normal speech. Demonstrates linear thinking.No SI/HI.Endorses SIEndorses HIExam consistent with gravely disabled.No AH/VH.Agitated.Confused.