mod_ Exam

  • [01] [1] EXAM:
    • [01] VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-assess patient):
      • [01] HR:
        • [01] normal HR.
        • tachyardic
        • __
      • [01] BP:
        • [01] normotensive.
        • hypertensive
          • [01] (attempted to inform pt to advise to f/u with PMD).
          • hypotensive.
          • __
      • [01] O2 sat:
        • [01] no hypoxia
        • hypoxic
        • __
      • [01] RR:
        • [01] normal RR
        • tachypnic
        • __
    • [01] [1] PHYSICAL EXAM:
      • [01] General:
        • [01] well nourished
        • no distress
        • mild distress
        • moderate distress
        • severe distress
      • [01] HEENT:
        • [01] vision grossly intact.
        • [01] hearing grossly intact.
        • __
      • [01] Cardiovascular:
        • [01] no r/m/g
        • [01] no LE swelling
      • [01] Pulmonary:
        • [01] Lungs CBTA,
        • [01] No respiratory distress,
        • [01] Speaking comfortably in full sentences.
        • I/E wheezing,
        • rales,
        • rhonchi
        • respiratory distress,
        • __
      • [01] GI:
        • [01] abd soft,
        • [01] abd non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ
        • TTP in RLQ
      • [01] Neuro:
        • [01] Normal LOC.
        • [01] No grossly focal neurological deficits.
        • Somnolent through protecting airway
        • __
      • [01] MSK:
        • [01] no deformities,
        • [01] moving all extremities
        • Non-ambulatory.
      • [01] Psych:
        • [01] Normal speech.
        • [01] Demonstrates linear thinking.
        • No SI/HI.
        • Endorses SI
        • Endorses HI
        • Exam consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.
        • __
      • __

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