Pt was seen with nurse on rounds
Chart, vitals and records were reviewed
SUBJECTIVE
==========
Pt is stable
S/p Tracheostomy and PEG placement
REVIEW OF SYSTEMS:
==================
GENERAL: no acute distress
HEENT: No reported headache, trauma, bleeding or deviation
Eyes: No reported visual changes or reaction changes.
Ears: No reported trauma, bleeding
Nose: No bleeding.
Throat: No reported deviation, lymphadenopathy, swelling or trauma
No reported issues with the tracheostomy
LUNGS: No reported change in breathing pattern, symmetry, distress or work of breathing
CARDIAC: No reported chest pain, change in rhythm, or rate
GI: no reported pain, swelling, distension
No reported issue with the PEG
GU: No reported hematuria, pyuria.
NEUROLOGIC: No reported neurologic changes
MUSCULOSKELETAL: no reported change in mobility, paralysis or
change in ROM when examined and routine care
VITALS
======
Reviewed
PHYSICAL EXAM
=============
GA: comfortable, no distress
HEENT: Atraumatic; normo-cephalic;
Eyes: EOMI, PERRLA
Nose: Nares patent, no sign of bleeding
Throat: Mouth is clear and no adenopathy, no deviation
NECK: Supple, no adenopathy, and no thyromegaly
Trach site is clean
Trach is working well
Pt has good tidal volume
LUNGS: No rhonchi, no wheezing. There is no visible work of breaking
or short of breath.
CHEST: Symmetrical excursion
CARDIAC: Regular, rate, & rhythm. Vital signs are reviewed as well
ABDOMEN: +BS, Soft, Non-distended, No obvious organomegaly, and no obvious masses
No peritonitis
The PEG site is clean without complication
EXTREMITIES: No cyanosis, No clubbing, No edema
NEURO: neurologically, the patient remains unchanged from
baseline
IMAGING
=======
I have personally reviewed the imaging studies
LABS:
=====
I have personally reviewed the lab results
ASSESSMENTS/DIAGNOSIS AND PLANS
================================
The patient is s/p tracheostomy and PEG placement
Doing well
Trach site is clean without complication
Good tidal volume
The abdomen is soft and PEG is working without
sign of complication.
Continue supportive care
Continue TF and advance