Subjective
No Acute Events overnight. Pt denies CP, SOB, ABD pain, N/V/F/C.
Objective
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
Normal Physical Exam
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
Normal Neuro Exam
CN2-12 intact b/l. EOMI. 5/5 strength in UE and LE. Intact sensation b/l. No dysmetria, no dysdokinesia. Neg protanator drift, neg romberg. Gait nl.
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
Brian Truong, p0503
Plan discussed with attending physician: Dr. *
