Blood in Stool Click or tap here to enter text Abdominal Pain Click or tap here

Blood in stool click or tap here to enter text

This preview shows page 4 - 8 out of 10 pages.

Blood in Stool Click or tap here to enter text. Abdominal Pain Click or tap here to enter text. Excessive Flatus Click or tap here to enter text. Food Intolerance Click or tap here to enter text. Rectal Bleeding Click or tap here to enter text. Other: Urgency Click or tap here to enter text. Dysuria Click or tap here to enter text. Burning Click or tap here to enter text. Hematuria Click or tap here to enter text. Polyuria Click or tap here to enter text. Nocturia Click or tap here to enter text. Incontinence Click or tap here to enter text. Other: Click or tap here to enter text. Stress Click or tap here to enter text. Anxiety Click or tap here to enter text. Depression Click or tap here to enter text. Suicidal/Homicidal Ideation Click or tap here to enter text. Memory Deficits Click or tap here to enter text. Mood Changes Click or tap here to enter text. Trouble Concentrating Click or tap here to enter text. Other: Click or tap here to enter text.
Image of page 4
Click or tap here to enter text. GYN Rash Click or tap here to enter text. Discharge Click or tap here to enter text. Itching Click or tap here to enter text. Irregular Menses Click or tap here to enter text. Dysmenorrhea Click or tap here to enter text. Foul Odor Click or tap here to enter text. Amenorrhea Click or tap here to enter text. LMP: Click or tap here to enter text. Contraception Click or tap here to enter text. Other: Click or tap here to enter text. O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.
Image of page 5
Body System Positive Findings Negative Findings General Obesity noted Well nourished, well dressed, well developed. Appropriate affect, alert, and cooperative. Normal speech, judgement and comprehension. Normal mood, no fever. Skin Acanthosis nigricans noted Skin of chest has no trauma, scares, rashes or lesions noted. HEENT Unable to Assess Unable to Assess Respiratory Wheezing heard in posterior bilateral lower lobes. Accessory muscle use noted. Spirometry results - FVC 3.91L, FEV1 3.15L = 80% percent predicted ratio No asymmetry noted in chest. No deformities noted in chest wall. No rales or rhonchi noted. No retractions noted. No dull areas noted during percussion. No absent breath sounds or diminished areas. No bronchophony noted Neuro Unable to Assess Unable to Assess Cardiovascular Unable to Assess Unable to Assess Musculoskeletal Unable to Assess Unable to Assess Gastrointestinal Unable to Assess Unable to Assess
Image of page 6
Problem List 1. Click or tap here to enter text. 6 Click or tap here to enter text. 11 Click or tap here to enter text. Click or tap here to enter text. 7 Click or tap here to enter text. 12 Click or tap here to enter text.
Image of page 7
Image of page 8

You've reached the end of your free preview.

Want to read all 10 pages?

  • Fall '15

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes