Patient: VH

Temperature: 36.2
Pulse: 82
Respiratory Rate: 21
Blood pressure: 129/68
Pulse Ox: 91.0%
Pain Score: 0/10
Allergies: NKA
Code Status: DNR
Weight: 61.47Kg
Height: 60”
BMI: 26.75
Diet: Regular supplement per facility protocol, fluid restriction to 1500cc every day
Ethnicity: White
Religion: Protestant

General:
Alert, oriented x3, awake, healthy appearing. Supine position on bed. No respiratory distress. Ambulatory aide is a walker, ambulating normally.
Mental Status:
Judgment and insight intact; oriented to time, place, and person; intact memory for recent and remote events.

Head/Hair:
Head is normocephal. Hair appears thin and gray. Scalp no signs of abrasions, masses or deformities, scalp is not dry, hair distribution even, hair free of infestations.

Nails:
Finger nails long, appearance of striae, surface has ridges. Capillary refill of 2 seconds, nails slightly rounded. Little black circle on left pinky above proximal nail fold. Toe nails long, thickened, yellowish color. End of toe nails are chipped, capillary refill of 1.5 seconds.

Skin/Extremities:
Warm to touch, dry, color is normal for patient’s ethnicity. Skin turgor elastic, and rapidly returns to original shape. Patient has scattered bruising on top of both thighs and up and down arms bilaterally. Fluid filled blisters and open sores scattered on both lower legs and feet bilaterally. Scabs scattered on lower legs and feet bilaterally, 70% yellowish drainage from open sores bilateral on lower legs. Both legs have evidence of varicose veins. Left lower leg has evidence of cellulitis. Capillary refill of 2 seconds, upper extremities no edema present. Lower extremities have evidence of edema, left ankle 2+ edema, right ankle 1+ edema. Both lower legs covered with telfa to open areas and blisters, legs wrapped with kerlix and secured with surgilast, iodine placed on scabs, open areas cleaned with normal saline.
Eyes:
Eyes symmetrical, no tearing, swelling, or drainage present. Sclera appears white, conjunctivae and lids normal, pupils equal, round, reactive to light and, accommodation, EOM intact.

Ears:
Same color as face, central position, proportional, external ear canals clear without drainage. No lesions or deformities, and hearing decreased.

Nose:
Symmetrical and in midline of face, no nasal crusting, sores or discharge, mucous membranes moist. No pain noted, bilateral patent nostrils.

Mouth:
Pink and moist, no abrasions or deformities. Tongue midline and moves freely. Lips are moist, no lesions or inflammation and symmetrical. Gums no swelling or bleeding. Patient wears full dentures fitting proper and comfortably.

Neck:
No masses, trachea midline, no tenderness, or enlargement, with full ROM without discomfort. Neck is symmetrical with head in central position.

Lungs:
Breathing unlabored, bilateral lungs clear to auscultation, chest excursion symmetric.

Heart:
Pulse strong and regular, S1, S2, rate and rhythm regular, no murmur.

Abdomen:
Soft, non-tender and non-distended abdomen with no masses; tenderness, bowel sounds regular x4 quadrants.

Musculoskeletal:
Normal alignment, mobility and no deformity of head, neck, spine, ribs and pelvis. Full ROM. Push and pull bilaterally equal in hands and feet. Grip bilaterally equal in hands. There was no joint enlargement and tenderness in the knuckles, and wrists, reflexes intact to touch.

Genitourinary
Patient refused genital and anus examination.

Surgeries:
Left knee replacement, hysterectomy, pacemaker, bilateral cataract surgery, Right digit 1 and 2 toe partial amputation, left breast lympectomy