Then begin your complete physical examination of the patient. If symptoms are restricted to a specific body system or region, a more limited examination may be appropriate. Document only what you carefully examine and only the things that are pertinent. Ex Pt is alert and oriented x 3, with alcohol noted on breath. Exam is essentially normal, ENT clear with mildly dry mucus membranes.
Lungs are clear.
Abdomen soft nontender, neg. rebound. Normal bowel sounds. STAT laboratory and X-ray results may be important in making the diagnosis. This is where you think through the results of the history and physical examination. PLAN Further diagnostic studies needed.