Review of Systems: (Subjective)
Neuro: Patient is unable to speak due to current diagnosis and placement of tracheostomy, but is also to gesture or write down things he wants to say. Patient declines any signs of headache, visual disturbances and also declines any history of numbness, seizures, or paralysis besides that of his vocal folds. Patient requested that the lights be turned down during the morning hours so he could try and sleep more between roundings due to not being able to sleep well in the hospital.
Cardio: Patient denies any sign of chest pain, dyspnea, palpitations, or peripheral edema.
Respiratory: Patient notes that he is comfortable being on room air at this point in his recovery. Patient denies any dyspnea on exertion, and states that he is using his incentive spirometer every 2 hours as prescribed.
GI: Patient reports that he is satisfied with his high protein formula for his PEG tube feedings, and no sign of stomach upset. Patient denies nausea or vomiting. Patient reports his last bowel movement was before coming to the hospital on 02/03/17.
GU: Patient reports no issues with urinating, and has a urinal available to use, though he prefers to get up to use the lavatory. Patient reports urine is clear and yellow.
Musculoskeletal: Patient states that while feeling tired, he does not feel weak. He tries to move around his room when he can and is scheduled to ambulate with PT at 1pm today.
Skin: Patient reports that his dressings feel dry, and that he has incisional pain, which his PRN dilaudid and Hycet have been adequately treating.
Psych: Patient reports feeling a little lonely, as he is close with his wife and adult daughter, but neither are able to visit during the week-day-hours. He is looking forward to getting discharged from the hospital so he can, “Get back to his life”, and training for the Austin triathlon occurring in May.
Environmental Health: He is excited to have the therapy dog come visit this afternoon, and asked his daughter to bring his dog to visit him after getting prior approval from nursing staff.