vomiting, blood or mucus in stool, recta fever. She denies vaginal bleeding or d of inflammatory bowel disease or GER disorders. Her appetite has decreased she is taking small amounts of water a reports regular brown soft stools every Objective Generl: Alert, oriented, appears uncomfortable, flushing of the cheeks, mily distressed. HEENT: mouth mucus membranes dry apperance. Cardiovascular: S1, S2, No extra sounds noted. Respiratory: Clear to auscultate, present all areas, no adventitious • General Survey: Uncomfortable and f woman seated on exam table grimacin but mildly distressed. • HEENT: Mucus Normal skin turgor; no tenting. • Cardio murmurs, gallops or rubs; no S3, S4 ru
Student Documentation Model Documentation sound noted Adominal: scarring approximately 6 cm in the RUQ and 10 cm in suprapubic area. Normoactive bowel sounds in all quadrant. Dullness over LLQ; otherswise tympany. Mass noted in the LLQ with guarding noted. No friction on liver or spleen. No CVA tenderness noted. Pelvic: no abnormal findings. Rectal: No hemorrhoid, nofissures, ulceration, strong sphincter tone, some fecal mass in rectal vault noted. Urinalysis: clear, dark yellow, No nitrites, WBCs, RBC, ketones. Ph 6.5, SG 1.017 edema. • Respiratory: Respirations qui speak in full sentences. Breath sounds Abdominal: 6 cm scar in RUQ and 10 c suprapubic region. An abdominal exam normoactive bowel sounds in all quadr
You've reached the end of your free preview.
Want to read all 3 pages?
- Fall '15
- Objective pronoun, Ms. Park, LLQ