Pt was seen with nurse on rounds
Chart, vitals and records were reviewed
SUBJECTIVE
==========
Pt is stable
S/p Tracheostomy
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
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
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
Doing well
Trach site is clean without complication
Good tidal volume
Continue supportive care