AR2728
Expert
I frequently use the 1997 guidelines, but am now finding some of our specialists may benefit using the 1995 guidelines. I find them to be more confusing and I am struggling. I would appreciate any feedback on the following exam audited using 1995 guidelines.
PHYSICAL EXAMINATION: When he came to the emergency room documented heart rate of 77. The patient was saturating at 87% to 91% on 2 liters nasal cannula. His blood pressure was 139/65. His telemetry strip read basically atrial flutter but a 2:1 or 3:1 block with diffuse P wave inversion which is secondary to the atrial flutter pattern. The patient's temperature was also 101.3. He was lying in bed comfortably. He was alert. He was not oriented to place.
CARDIAC EXAM: Showed regular rate and rhythm. S1, S2 were heard. Heart sounds were
distant. No obvious murmurs, rubs or gallops were noted.
LUNGS: Examination of the lungs posteriorly revealed bibasilar rales. The upper lung zones were clear to auscultation posteriorly.
ABDOMEN: Soft. Non-tender. Non-distended. Positive bowel sounds throughout. No rebound, rigidity, or guarding were noted.
EXTREMITIES: The lower extremities revealed +2 pitting edema.
One additional question: The physician states for ROS: unobtainable as patient does not give a proper history. So, he has nothing for ROS--correct?
Thanks for the assistance.
PHYSICAL EXAMINATION: When he came to the emergency room documented heart rate of 77. The patient was saturating at 87% to 91% on 2 liters nasal cannula. His blood pressure was 139/65. His telemetry strip read basically atrial flutter but a 2:1 or 3:1 block with diffuse P wave inversion which is secondary to the atrial flutter pattern. The patient's temperature was also 101.3. He was lying in bed comfortably. He was alert. He was not oriented to place.
CARDIAC EXAM: Showed regular rate and rhythm. S1, S2 were heard. Heart sounds were
distant. No obvious murmurs, rubs or gallops were noted.
LUNGS: Examination of the lungs posteriorly revealed bibasilar rales. The upper lung zones were clear to auscultation posteriorly.
ABDOMEN: Soft. Non-tender. Non-distended. Positive bowel sounds throughout. No rebound, rigidity, or guarding were noted.
EXTREMITIES: The lower extremities revealed +2 pitting edema.
One additional question: The physician states for ROS: unobtainable as patient does not give a proper history. So, he has nothing for ROS--correct?
Thanks for the assistance.