Urgency Denies Dysuria Denies Burning Denies Hematuria Denies Polyuria Denies

Urgency denies dysuria denies burning denies

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Urgency Denies Dysuria Denies Burning Denies Hematuria Denies Polyuria Denies Nocturia Denies Incontinence Denies Other: Click or tap here to enter text. Stress Denies Anxiety Denies Depression Denies Suicidal/Homicidal Ideation Denies Memory Deficits Denies Mood Changes Denies Trouble Concentrating Denies Other: Click or tap here to enter text. GYN
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Rash Denies Discharge Denies Itching Denies Irregular Menses Denies Dysmenorrhea Denies Foul Odor Denies Amenorrhea Denies LMP: Did not assess Contraception Denies 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.
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Body System Positive Findings Negative Findings General Click or tap here to enter text. Patient is alert and oriented, normal stature Skin Moles assessed on right upper back, skin discoloration of neck, and observed facial acne. Click or tap here to enter text. HEENT Click or tap here to enter text. Click or tap here to enter text. Respiratory Auscultated adventitious breath sounds bilaterally, in posterior lower lobes, wheezing noted in bilateral posterior, lower lobes. Chest inspection: symmetrical, Palpated: equal expansion bilaterally, expected fremitus, Percussed Chest wall : No dullness, Auscultated: normal breath sound in anterior upper and lower lobes. Neuro Click or tap here to enter text. Click or tap here to enter text. Cardiovascular Click or tap here to enter text. Click or tap here to enter text. Musculoskeletal Click or tap here to enter text. Click or tap here to enter text. Gastrointestinal Click or tap here to enter text. Click or tap here to enter text. Genitourinary Click or tap here to enter text. Click or tap here to enter text. Psychiatric Click or tap here to enter text. Click or tap here to enter text.
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Problem List 1. Chest tightness 6 Click or tap here to enter text. 11 Click or tap here to enter text. 2 Wheezing 7 Click or tap here to enter text. 12 Click or tap here to enter text. 3 shortness of breath 8 Click or tap here to enter text. 13 Click or tap here to enter text. 4 Click or tap here to enter text. 9 Click or tap here to enter text. 14 Click or tap here to enter text. 5 Click or tap here to enter text. 10 Click or tap here to enter text. 15 Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings Mild intermittent asthma, with acute exacerbation J45.21 Symptoms started after cat exposure, Reports feeling better after use of inhaler on and off. Wheezing R06.2 Reports wheezing and Ausculatated wheezing in the posterior bilateral lower lobes of patient lungs. Shortness of breath R06.02 Reports trouble catching breath Diagnostics: List tests you will order this visit Test Rationale/Citation ABG To check if patient is well oxygenated (mendes, 2019). Click or tap here to enter text. Click or tap here to enter text.
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