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Discussion

Charting descriptions

Hello, I am having difficulty coming up with descriptive words for lung sounds and heart sounds and bowel sounds in my charting without using the word "normal" which is off-limits by our instructor. Any ideas for describing something that sounds normal in other words??

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Lungs clear to auscultation (CTA) No wheezes, railes or (SOB) shortness of breath present. No stridor present.

Bowel sounds present, gastric motility noted.

Heart rate regular, strong....

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Thank you! That was easy enough. Except...what does the abbreviation CTA stand for?

Bowel sounds present in all 4 quads.

Thank you! That was easy enough. Except...what does the abbreviation CTA stand for?

clear to auscultation

Heart rate regular without murmur

I have physical assessment on Thursday and we have to be descriptive and detailed as well.

I have physical assessment on Thursday and we have to be descriptive and detailed as well.

Heart sounds s1 = s2 " apical sounds s1=s2."

Bowel sounds = positive borborygmous " positive borborygmous sounds over RLQ"

normal breathing = eupniec " patient is eupniec."

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