Physicial examination

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Shoshana
Posts: 76
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Tue Feb 13, 2018 11:58 am

If a physician puts "benign" on abdominal examination, is this acceptable? Would this be the same as stating "WNL"?

Physicial Examination:
Vital Signs: Temp 98.3, HR 79 RR 17 BP 131/58 Sat 97%
General: She is disorganized perseverating about adopting a child in China. She is uncooperative to the physical exam.
Lungs: Clear
CV: Normal rate, rhythm
abdomen: benign
Lower extremities: with cigarette burn on the left side of the LLL. no edema.
Neurologic: Exam seems to be nonfocal.

I get 7 elements with none in detail if you count abdomen as WNL. Can someone else double check this?
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