patient physical exam:
CV: NSR, cap refill less than 3 secs. S1S2 auscultated, pulses equal, reg, +2 bilaterally,
Resp: Lungs clear bilaterally, regular, unlabored.
Pupils: unequal, L 3mm, R 5mm
Neuro: LOC: obtunded, patient has Lsided upper/lower extremity weakness, no effort against gravity. DTR absent. R side Upper/lower extremity have tone and withdraw from pain. DTR present. neg Babinski reflex bilaterally. Unable to perform full CN assessment, pt has a forced right sided gaze.
GI: bowel sounds active all quadrants. pt has emesis in OG tube and suction canister
GU: Foley catheter placed, no s/s irritation. pt has 300ml yellow urine in collection bag.
MS: pt has tone in R upper/lower extremity. no tone or effort left upper/lower extremity.
Integ: no s/s of skin breakdown, pt appears well nourished, skin is pink, warm and dry. turgor within normal limits.
Pain: CPOT pain scale for intubated patients: 5. needs pain management.
Ht: 175cm
Wt: 118 kg.