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

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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 templat

Post by answerhappygod »

NEED HELP ON THIS RIGHT NOW! VERY URGENT!
Use the provider’s dictation below to correctly document
the following template physical
exam.
Patient is in acute respiratory distress. Right lung has
crackles at the base and a wet cough. Heart was mildly tachycardic
at 105 bpm. Everything else was normal.
Constitutional: No acute distress, non-toxic
appearance.
HENT: Head is atraumatic, moist mucous
membranes, normal oropharynx, TMs clear.
Eyes: Conjunctiva normal, PERRL.
Neck: Normal ROM, supple.
Respiratory/Chest: No respiratory
distress, lungs clear to auscultation.
Cardiovascular: Normal rate and rhythm, no
murmurs, no gallops, no rubs.
GI: Soft, nondistended, nontender, no
mass, no rebound, no guarding.
Musculoskeletal: No extremity tenderness,
no deformities.
Back: No tenderness.
Skin: Warm and dry, no rash.
Neurologic: Alert & oriented x 3,
strength normal, no sensory deficits noted, CN II-XII grossly
intact.
Psychiatric: Speech and behavior
appropriate.
Lymphatic: No lymphadenopathy noted.
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