words per minute
7
aMAXiMINalist
00:00
Speed
Gen: awake, alert, no acute distress, cooperative
Head/eyes: normocephalic, EOMI, PERRL(A)
ENT: atraumatic, moist mucous membranes
Resp: No distress, normal breath sounds, no wheezes, no rales, no rhonchi
Cardio: regular rate, normal rhythm, normal heart sounds
Abd: Soft, nontender, no guarding, no rebound, no distention
Ext: non-tender, no swelling
Neuro: Alert, orientedx3, normal speech
Psyche: normal mood, normal affect, normal judgment
Skin: normal color, warm, dry intact
Re-eval: Pt in NAD and well appearing. Discussed results/dx and counseled pt on plan of care. Recommended dc home w/ instructions to f/u w/PCP (or specialist). Precautions given to return to ED w/new or worsening Sxs. Pt understands and agree w/ dc home.
BMP: Na, K, glucose, Bun?, creatinine
CBG: WBC, HGB, Platelets
UA: Blood, ketones, glucose, protein, leuks, nitrates
WBC, RBC (yes, include them.)
LFT: T Bili, D bile