Answer Happy

NEED HELP ON THIS RIGHT NOW! VERY URGENT!
Use the provider’s dictation below to correctly document
the following template physical
exam.
Patient has widespread dental decay with multiple caries. No
tenderness of the jaw. Some crackles in the left lung base with no
wheezes or rales. No respiratory distress. Some mild LLQ tenderness
to palpation with some rebound but no guarding. DRE was GUAIAC
negative with brown stool. 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.