NEED HELP ON THIS RIGHT NOW! VERY URGENT! Use the provider’s dictation below to correctly document the following blank p

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answerhappygod
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NEED HELP ON THIS RIGHT NOW! VERY URGENT! Use the provider’s dictation below to correctly document the following blank p

Post by answerhappygod »

NEED HELP ON THIS RIGHT NOW! VERY URGENT!
Use the provider’s dictation below to correctly document
the following blank physical exam.
Patient has a three by two cm laceration to the right thumb,
just proximal to the PIP joint. No other injuries noted to the
right arm. There are no injuries to the left arm. There is another
laceration to the right lower leg with some tissue avulsion noted
as well. It’s about 4 cm in length by 2 cm wide and is gaping. Left
leg is normal. Head is atraumatic, no battle signs or raccoon eyes.
Abdomen was soft and nontender. No guarding or rebound, no mass. No
distension. Back had very mild midline tenderness from L2-L4. Heart
had regular rate and rhythm. Lungs were clear to auscultation with
no wheezing, rales, rhonchi, or crackles. Breath sounds equal
bilaterally. DRE was GUAIAC negative.
Constitutional:
HENT (Head, Ears, Nose, Throat):
Eyes:
Neck:
Respiratory/Chest:
Cardiovascular:
GI:
Musculoskeletal:
Back:
Skin:
Neurologic:
Psychiatric:
Lymphatic:
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