HH Emergency Dept/OBS Unit Documentation

er.txt

  PHYSICAL_EXAM:
  VS: afebrile, 
  GENERAL_APPEARANCE: well_nourished, alert, oriented_X_3, no_acute_distress, no_obvious_discomfort
  HEAD: no_swelling\tenderness on the head.
  EYES: PERRL, EOMI, conjunctiva_clear.
  MOUTH: (-)decreased moisture
  NECK: supple, no_neck_tenderness
  LUNGS: no_wheezing, no_rales, no_rhonchi, (-)accessory muscle use, good air exchange bilateral
  HEART: normal_rate, normal_rhythm, normal_S1, normal_S2, (-)S3, (-)S4, no_murmur, no_rub
  ABDOMEN: normal_BS, soft, no_abd_tenderness, (-)guarding, (-)rebound, no_organomegaly, no_abd_masses
  EXTREMITIES: good pulses on all_extremities,no_swelling\tenderness on the extremities, no_edema
  SKIN: warm, dry, good_color, no_rash, no_abrasions\lacerations
  NEURO: motor_intact, sensory_intact