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Question regarding physical exam

Posted By: JustMe on 2008-04-07
In Reply to:

Subject: Question regarding physical exam

Rhythm is _________.  (dictator cuts word off)


Axilla without s/l adenopathy.




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PHYSICAL EXAMINATION: Significant findings for left lower quadrant tenderness. Blood pressure was 124/78, pulse rate of 96, and respiratory rate of 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.


I would type it this way or at least make it present tense.  On my accounts, I am required to categorize these things. 


PHYSICAL EXAMINATION:


Abdomen:  Significant findings for left lower quadrant tenderness. Vital signs:  Blood pressure 124/78, pulse rate 96, respiratory rate 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.


 


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Subject: physical exam help

Physical exam, under Extremities, doctor states ___ pulses throughout.


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EXAMINATION:  No costovertebral angle tenderness.  Abdomen has normal active bowel sounds in all quadrants.  It is supple.  Extremely tender left upper quadrant and going down not quite into the groin.  Difficult to check the (s/l sternal) border because of increased tenderness but the spleen may be mildly enlarged but no distinct masses felt.  I am unable to check for rebound or guarding because she is so exquisitely tender with even a very light touch.


 


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Subject: physical exam

Probably just means + (the plus sign), as in positive S1, S2...just means he heard 1st and 2nd heart sounds clearly (as opposed to sounds to distant or obscured by extra sounds). If something was dictated before that, I would put a comma and use the plus sign, i.e., PREVIOUS TEXT, + S1, S2. If nothing precedes it, I would type positive S1, S2. If account wants verbatim, give it to them.
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However, I do think it was "cervical or" inguinal adenopathy.  This guy is a real mush mouth.  THANK YOU ALL SO MUCH FOR YOUR HELP!  I am sorry I wasn't clear enough earlier in my first message.  I really do appreciate your help.  This is a great board to come to--everyone is so knowledgeable! 
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I am wondering if, in the last sentence, where "drop can arc" is dictated . . . would she be referring to three tests/maneuvers such as Drop Arm, Empty Can, and an Arc test, or is it correct as is?


She has excellent range of motion of the shoulder.  Good grip strength.  Distal pulses and sensation are intact.  She can do a full drop can arc.


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