Head to Toe Assessment
10/29/210 0900---------------------------------------------------------------------------------------
Vital Signs: Temperature 98.8 Respirations 18 Pulse 84 BP 124/72.
Patient lying in semi fowlers in bed, polite and well groomed. Alert and oriented x4 (person, place, time), answers questions appropriately and patient denies having any allergies.Head: clean hair, well kept, facial features symmetrical, clear speech, PEARRLA, no drainage from eye or ears, mucus membranes moist and pink, teeth in good condition, no observed mouth ulcers. Neck supple, without palpable nodes, no vein distention. Patient able to move head in all directions well. Lungs clear throughout, symmetrical expansion with inspiration, clear to auscultation. No cough as also denied by patient. Heart S1 S2 noted, no mummer, strong distal pulses radial, dorslas pedius. Pink nailbeds with capillary refill < 3 seconds in all extremities. Breast symmetrical, without dimpling, or skin lesions, areola symmetrical nipple without cracks or lesions. Patient able to move arms easily, firm equal grips, no edema noted. Patient has a 20 gauge saline lock to left lateral forearm. Site is free from redness or drainage, with Tegaderm dressing intact. Abdomen soft, non tender, bowel sounds present x 4 quadrants. Foley catheter inserted on 10/28/10 is intact and clean. Urine is not concentrated and is clear and yellow with an output of 40ml for this hour. Bladder is non-distended. Last BM was 10/27/10. No observation of flatulence. Patient denies constipation, diarrhea, or pain. Patient denies urinary symptoms, denies urgency, frequency, or dysuria. Genital Symmetric, no lesions noted. Able to move all lower extremities, no pitting edema noted on upper and lower extremities. Peripheal pulses 2+ on both upper and lower extremities. No lesions noted, skin
Vital Signs: Temperature 98.8 Respirations 18 Pulse 84 BP 124/72.
Patient lying in semi fowlers in bed, polite and well groomed. Alert and oriented x4 (person, place, time), answers questions appropriately and patient denies having any allergies.Head: clean hair, well kept, facial features symmetrical, clear speech, PEARRLA, no drainage from eye or ears, mucus membranes moist and pink, teeth in good condition, no observed mouth ulcers. Neck supple, without palpable nodes, no vein distention. Patient able to move head in all directions well. Lungs clear throughout, symmetrical expansion with inspiration, clear to auscultation. No cough as also denied by patient. Heart S1 S2 noted, no mummer, strong distal pulses radial, dorslas pedius. Pink nailbeds with capillary refill < 3 seconds in all extremities. Breast symmetrical, without dimpling, or skin lesions, areola symmetrical nipple without cracks or lesions. Patient able to move arms easily, firm equal grips, no edema noted. Patient has a 20 gauge saline lock to left lateral forearm. Site is free from redness or drainage, with Tegaderm dressing intact. Abdomen soft, non tender, bowel sounds present x 4 quadrants. Foley catheter inserted on 10/28/10 is intact and clean. Urine is not concentrated and is clear and yellow with an output of 40ml for this hour. Bladder is non-distended. Last BM was 10/27/10. No observation of flatulence. Patient denies constipation, diarrhea, or pain. Patient denies urinary symptoms, denies urgency, frequency, or dysuria. Genital Symmetric, no lesions noted. Able to move all lower extremities, no pitting edema noted on upper and lower extremities. Peripheal pulses 2+ on both upper and lower extremities. No lesions noted, skin