ASSESSMENT
VIEW COMPLETED NOTE
Head to toe assessment: Patient is alert, oriented to person, time and place. Responsive to touch and verbal orders, presents with adequate hearing and speech clear. Affect and facial expression appropriate to situation. Grips, flexion, extension strong bilaterally. Respiration even and unlabored. No accessory muscles used. Breath sounds clear in all areas. Chest expansion symmetric. No pain or tenderness on palpation. Percussion tones resonant over all lung fields. Vesicular breath sounds auscultated over lung fields. No adventitious sounds present. Respiratory Rate: 18 bpm, SpO2: 98%. Heart sounds: Regular rate and rhythm: S1/ S2 normal; no murmur, rub or gallop. Peripherals pulses present and normal. The jugular veins are not visible. No edema. Capillary refill <3 sec. Blood Pressure: 120/80 (mm Hg, Hearth Rate: 60 bpm. Abdomen soft, non-tender, non-distended, bowel sounds present in all quadrants. Skin warm and dry to touch, turgor good, no skin lesions or breakdown, Temperature: 97.6 °F. Both extremities are equal in size. Have the same contour with prominences of joints. Can perform complete range of motion. No pain. No Foley catheter, Pacemaker, Peg tube, Oxygen, drain, IV line.
VIEW COMPLETED NOTE
Past Medical History: Congestive Heart Failure (CHF), Arrhythmia, HTN, Catarata surgery. VITAL SIGNS: Temperature: 98°F, Place: Axillary, Pulse: 66bpm, P Place: Radial, P Rhythm: Regular. Respiration: 18 rpm, R Rhythm: Regular. BP: 122/76 mm/Hg, BP Place: Right, BP Position: Sitting. Blood Sugar: 98 mg/dl, Meal: Fasting. VS Comments: No comment. CARDIOVASCULAR. Chest Pain: No, Heart Sounds: Present and normal, Capillary refill: < 3 Sec, Peripherals Pulses: present and normal, Edema: No edema, Neck Vein Distention: None, Dizziness: None, Fainting: None, Pace marker: N/A, Cardiovascular Comments: No comment. RESPIRATORY. Lung Sounds 1: CTA: Bilateral; Lung Sounds 2: Dimished: Bilateral Bases, SOB: With moderate exertion, Sputum: No sputum, Cough: Non-productive, Via Oxygen: Nasal cannula, Oxygen: 2 lpm, O2 Sa: 95%, Nebulizer: Albuterol, Respiratory Comments: No Covid-19. NEUROLOGICAL. Oriented to: Person, Place, Time, Forgetful, PERRL, Tremors Location: None, Sensory: Within normal limits, Hearing Impaired: No, Vision: Glasses, Decreased Sensation: None, Pain: Low back. Frequency of pain: daily, but not constantly, Pain Intensity: 2/10, Neurological Comments: No comment. GENITOURINARY. Genitourinary: Retention, Catheter: Foley, Last Changed: 2022-02-07, Urine: Yellow and clear, External Genitalia: Normal, Genitourinary Comments: No comment. DIGESTIVE/NUTRITION. Digestive-Nutrition: , Weight Loss/Gain: -10 pounds, Bowel Sounds: Normal, Abd Girth: 100 cm, Last BM: 02/06/22, Stool: Normal, Diet: NAS, NCS, Other Diet: no, Digestive Comments: No comment. SKIN. Skin: Warm, Dry, Turgor: Decreased, Skin Conditions: , Skin Comments: Ulcer left leg II. PSYCHOSOCIAL. Psychosocial: Within normal limits, Psychosocial Comments: No comment.
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