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
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physical exam
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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Subject: It was just a physical exam, and I don't know
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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Subject: Under physical exam...
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Subject: physical exam
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