NEED HELP ON THIS RIGHT NOW! VERY URGENT! Use the provider’s dictation below to correctly document the following templat
Posted: Tue Feb 15, 2022 3:50 pm
NEED HELP ON THIS RIGHT NOW! VERY URGENT!
Use the provider’s dictation below to correctly document
the following template physical
exam.
Bruising and swelling over the right forehead. Vision
intact, globes intact. Visual acuity: 20/20 bilaterally. The
abdomen was soft and nontender, no rebound or guarding. The right
elbow was slightly swollen with some decreased ROM secondary to
pain, but while the patient was distracted I was able to fully
extend and flex the arm at all joints. There is some mild
paraspinal musculature tenderness over the lumbar spine around L3
to L5, but no midline tenderness. Subjective sensory deficit noted
to the median distribution of the right hand, but sensation appears
to be intact otherwise. Strength intact to bilateral upper and
lower extremities. Moderate lymphadenopathy noted to the anterior
cervical region. Right knee is mildly tender, but retains full ROM.
Exam was otherwise 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.
Use the provider’s dictation below to correctly document
the following template physical
exam.
Bruising and swelling over the right forehead. Vision
intact, globes intact. Visual acuity: 20/20 bilaterally. The
abdomen was soft and nontender, no rebound or guarding. The right
elbow was slightly swollen with some decreased ROM secondary to
pain, but while the patient was distracted I was able to fully
extend and flex the arm at all joints. There is some mild
paraspinal musculature tenderness over the lumbar spine around L3
to L5, but no midline tenderness. Subjective sensory deficit noted
to the median distribution of the right hand, but sensation appears
to be intact otherwise. Strength intact to bilateral upper and
lower extremities. Moderate lymphadenopathy noted to the anterior
cervical region. Right knee is mildly tender, but retains full ROM.
Exam was otherwise 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.