Subjective
Pt is stable
no new complaints today
REVIEW OF SYSTEMS:
GENERAL: No malaise. No weight loss.
HEENT: No CO headache.
Eyes: No CO decreased vision.
Ears: No CO decreased hearing.
Nose: No bleeding.
Throat: No sore throat. Denies and mass or lesion
LUNGS: No shortness of breath. No cough. No increased work of breathing
CARDIAC: No chest pain. No palpitations. No swelling or edema
GI: no nausea,
no pain
GU: No frequency. No hesitancy. No hematuria. No pyuria.
NEUROLOGIC: No dizziness. No neuropathy. No CVA. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - No breakdown
Vitals:
Reviewed
Physical Examination
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
LUNGS: No rhonchi, no wheezing
CHEST: Symmetrical excursion
CARDIAC: Regular, rate, & rhythm
ABDOMEN: +BS, Soft, Non-distended, No obvious organomegaly, and no obvious masses
No peritonitis
EXTREMITIES: No cyanosis, No clubbing, No edema
SKIN: No lesions
NEURO: Alert Ox3, CN11-12 are intact, motor and sensory grossly intact
Imaging:
I have personally reviewed the imaging studies
Labs:
I have personally reviewed the lab results
Assessments and Plans:
Patient is stable
Await GI function
Continue IV fluid