Grossly intact. No rash. No lesions. Erythema to LUE.
What is no rash
100
Right upper quadrant tenderness
What is nontender abdomen
100
LLQ
What is left lower quadrant
100
Accessory muscle use
What is pulmonary
200
Jaundice
What is skin
200
CTA bilaterally. No retractions. Scattered coarse breath sounds
What is CTA bilaterally
200
Phayrngeal erythema
What is oropharynx normal
200
JVD
What is jugular vein distention
200
Edentulous
What is ENT
300
Anxious
What is psychiatric
300
Neck is supple without significant adenopathy or mass. Oropharynx clear with moist mucous membranes. Nuchal rigidity.
What is neck is supple
300
1+ left radial pulse.
What is 2+ left radial pulse
300
CTAB
What is clear to auscultation bilaterally
300
Capillary refill less than 2 seconds
What is circulatory
400
Adnexal tenderness
What is GU
400
The abdomen is soft and nontender. There is no palpable mass, organomegaly, guarding or rebound. Bowel sounds are physiological. Negative Murphy's sign. No McBurney's point tenderness. Negative Rovsing's signs
What is no contradictions.
400
Cachectic
What is well nourished
400
DP
What is dorsalis pedis
400
4/5 strength in LUE
What is neurological
500
Voluntary guarding
What is abdominal
500
Awake and alert. CN II-XII grossly intact. No focal neurological deficits. Hypoesthesia to right thumb.