Bill Buxton- Ihuman Guide Vitals Documentation: ● Pulse : Good, all correct. (FYI actual rate: 92) ● Respiration : correct is normal . (FYI actual rate: 20) ● BP : Good, all correct. (FYI actual BP: 162/92) ● Mental Status : Good, all correct. Exam Documentation: ● Lung Auscultation : ● Left: Correct is fine crackles . ● Right: Correct is fine crackles . ● Cardiac Auscultation : Correct is Murmur - pansystolic . ● Eyes - Pupils : Good, all correct. ● Eyes - H-Test : Good, all correct. Key Finding MSAP Relation Shortness of breath (SOB), tachypnea, PND MSAP Fluid retention: peripheral leg edema (2+) and abdominal edema, ascites, hepatic congestion RELATED Elevated jugular venous pressure (JVP) RELATED Fine crackles in lung bases RELATED S3, S4 with pansystolic murmur RELATED Displaced PMI 2 cm lateral RELATED Capillary refill delayed RELATED Hypertension RELATED Tachycardia RELATED Positive JVP with hepatojugular reflux RELATED 50 pack-year history of smoking, quit 6 mo ago UNKNOWN Cough (white frothy sputum) UNKNOWN Indiscriminate salt intake UNKNOWN Hx of coronary artery disease UNKNOWN
Bill Buxton- Ihuman Guide Obesity UNKNOWN Fatigue RELATED Hepatomegaly RELATED
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- Spring '16
- Shelley Ashby