Name: Bob Blue         Pt. ID#: 0000002         Bed: 486
Admitting diagnosis: MI                     Admitting physician: Dr. Doolittle
Allergies: PCN
Yesterday – on admission

Mental Status
alert & oriented to person, place, time
Mood & affect:                   pleasant    
Behavior:             cooperative    
Comments:
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Pain/Comfort
Verbalizes pain level on 0-10 scale: 10        Location: chest
Quality: dull         other- describe: pressure
Comments:
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Head & Neck
Oral cavity:         moist                     
Sclera/conjunctiva:           clear      
Pupils:                   equal     
Pupil reaction:                    R: brisk    pupil size: 2mm
L: brisk    pupil size: 2mm
Comments:
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Chest:
O2Sat:  92%         Respiratory rate: 28                    Respiratory effort:              abnormal-describe: reports difficulty “catching breath”
Breathe sounds:                  equal      clear       l   
Cough:  n/a        
Oxygen: NC- 4L/min        
cool mist vaporizer
Chest tube:  
Comments:
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Heart sounds:
Apical pulse: 98 regular                   Monitor – sinus rhythm  
Comments:
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Gastrointestinal
Abdomen:          soft         nondistended       
Bowels sounds:    active x 4 quadrants          
Comments:                
Last BM: yesterday                           
Comments:
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Genitourinary
Urine:                   
foley- 18g              Date inserted: today

Urine color:  yellow   clear    
Comments:
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Peripheral
Radial pulses:      equal/bilateral
R:  +2  
L: +2 
Dorsalis pedis:    equal/bilateral
R: +2 
L: +2 
Posterior tibial:  equal/bilateral
R: +2 
L: +2 
Capillary refill:  4 seconds          
Comments:       
Handgrips:           equal/bilateral
R:            weak     
L:            weak     
Movement upper extremities:         equal/bilateral
R:            weak     
L:            weak     
Movement lower extremities:         equal/bilateral
R:            weak     
L:            weak     
Comments:       
Sensation:              present/appropriate           
Comments:
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Integument
Skin:      moist      cool       
 
Color:    pale   
Turgor: elastic
Nailbeds: other: pale
Edema: absent   
Comments:
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IV sites
IV start date: today
peripheral-catheter gauge: 16g        
Location: Right antecubital             
IV infusing- LR @ 100ml/hour   pump #: 3421
no redness, occlusive dressing intact
Comments:
Additional IVs:                   N/A  

Wounds/incisions:  n/a
Drains/Tubes:  n/a     

Isolation:  n/a     
Comments:      
Fall Precautions:   active
Decubitus Precautions: n/a