Physical Assessment First admission
NEURO: A&OX4, alert to person, place, time and situation. Face grimacing
RESP: Pt lungs are CTA and non-labored respiratory effort.
CV: Pink, warm and dry, 1+ pitting edema lower extremities, heart sounds regular-S1S2, pulses strong, equal with palpitation at radial/pedal/post-tibial landmarks
GI: Abdomen distended, large-rounded-firm to touch, bowel sounds audible per auscultation in all 1 quadrants, bruising on abdomen.
GU: Voiding without difficulty, urine clear/light orange, loss of pubic hair
Skin: Skin is intact, color normal for patient, sclera of eyes light yellow in color, lips, and oral mucosa tacky dry, softball-sized ecchymosis on abdomen
Physical assessment last admission 6 months later:
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Jaundiced, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Confused and disoriented to person, place, time, and situation (x4), Disheveled, clothing dirty, has strong body odor, appears unkempt, does not smell of ETOH
GI: Abdomen protuberant–distended, bowel sounds audible per auscultation in all 4 quadrants
GU: Voiding without difficulty, urine clear/orange
SKIN: intact, skin is yellow/jaundiced in color with yellow sclera
VITAL SIGNS first admission
BP: 128/88
HR: 110
RESP: 20
SPO2: 95% RA
Temp: 100.5 F
ORTHOSTATIC BP
Lying: HR: 110 BP: 128/88
Standing: HR: 132 BP: 124/80
VITAL SIGNS Last admission
BP: 88/50
HR: 119
Temp: 99.5
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