Physicial examination

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Physicial examination

Postby Shoshana » Tue Feb 13, 2018 4:58 pm

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?
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Shoshana
 
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Location: Multi-specialty Clinic

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