clbarry8033
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I was hoping someone could help me determine how you would break this exam apart, or even if you can?
Physical Exam:
Vital Signs: Temp 36.2, pulse 82, resp. rate 24, BP 158/102, pulse ox 96%.
General: 45 yo white male, appears stated age. Well developed, well nourished. Slightly obese. Appears to be well hydrated. AAOx3. In no acute distress.
HEENT: Head atraumatic, normocephalic. Eyes: extraocular movements are intact b/l. Sclerae are clear b/l. Ears: External ears are normal. Hearing is normal. Nose: Nares are patent. No rhinorrhea. Mouth and throat: Mucous membranes are moist. Dentition is fair.
Neck: Supple
CV: Regular rate and rhythm. S1 and S2. I do not appreciate any murmurs, gallops, or rubs.
Lungs: He does have crackles noted in left base. No wheezing or rhonchi.
Abdomen: Soft. He denies tenderness with palpation. No rebound. No guarding. Bowel sounds present x4.
Extremities: No clubbing, cyanosis, or edema. Pulses are present b/l upper and lower extremities.
Skin: Warm, dry, and intact.
Neurologic: No focal deficits.
Thanks for all your help!
Physical Exam:
Vital Signs: Temp 36.2, pulse 82, resp. rate 24, BP 158/102, pulse ox 96%.
General: 45 yo white male, appears stated age. Well developed, well nourished. Slightly obese. Appears to be well hydrated. AAOx3. In no acute distress.
HEENT: Head atraumatic, normocephalic. Eyes: extraocular movements are intact b/l. Sclerae are clear b/l. Ears: External ears are normal. Hearing is normal. Nose: Nares are patent. No rhinorrhea. Mouth and throat: Mucous membranes are moist. Dentition is fair.
Neck: Supple
CV: Regular rate and rhythm. S1 and S2. I do not appreciate any murmurs, gallops, or rubs.
Lungs: He does have crackles noted in left base. No wheezing or rhonchi.
Abdomen: Soft. He denies tenderness with palpation. No rebound. No guarding. Bowel sounds present x4.
Extremities: No clubbing, cyanosis, or edema. Pulses are present b/l upper and lower extremities.
Skin: Warm, dry, and intact.
Neurologic: No focal deficits.
Thanks for all your help!