Bill Buxton-BEST Ihuman Guide-latest

2022-2023

Bill Buxton-BEST Ihuman Guide-latest

2022-2023

Vitals Documentation:

● Pulse: Good, all correct. (FYI actual rate: 92)

● Respiration: correct is normal. (FYI actual rate: 20)

● BP: Good, all correct. (FYI actual BP: 162/92)

● Mental Status: Good, all correct.

Exam Documentation:

● Lung Auscultation:

● Left: Correct is fine crackles.

● Right: Correct is fine crackles.

● Cardiac Auscultation: Correct is Murmur - pansystolic.

● Eyes - Pupils: Good, all correct.

● Eyes - H-Test: Good, all correct.

Key Finding MSAP Relation

Shortness of breath (SOB), tachypnea, PND MSAP

Fluid retention: peripheral leg edema (2+) and abdominal

edema, ascites, hepatic congestion

RELATED

Elevated jugular venous pressure (JVP) RELATED

Fine crackles in lung bases RELATED

S3, S4 with pansystolic murmur RELATED

Displaced PMI 2 cm lateral RELATED

Capillary refill delayed RELATED

Hypertension RELATED

Tachycardia RELATED

Positive JVP with hepatojugular reflux RELATED

50 pack-year history of smoking, quit 6 mo ago UNKNOWN

Cough (white frothy sputum) UNKNOWN

Indiscriminate salt intake UNKNOWN

Hx of coronary artery disease UNKNOWN

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