User:Homeostasisatwork

Pt is alert and orientated and able to answer all questions pertaining to their condition appropriately

Pt was found

A- patent, self-maintained

B- regular rate and rhythm, sufficient

C- no bleeds, good colour

NEURO Gcs15, no headache, normal vision, no dizziness, normal gait, good coordination, no swallowing difficulty, does not seem anxious, good memory, PERLAC TUG less than 15s, FAST -ve

RESP No SOB, no SOBOE, no WOB, no distress, good tidal vol, no jvd, moist mucosa, SpO2 over %ORA, clear lung sounds, no trach tug, speaking full sentences, No cough, no coryza

CARDIAC Strong reg rad, Normotensive, afebrile, NSR on 12/3lead, no CP, no diaphoresis, good colour, no pedal oedema, Normal skin temp to touch, good CRT, good turgor

GI/GU No n/v/d, no pain, no distention, eating well, well hydrated, normal recent BM, normal recent urination

MSS No significant injuries, no open wounds, good ROM, doesnt use a walker

OTHER No recent medication changes, no recent medical visits, No signs of infection

SOCIAL Independent, lives with family, works, Good social support, good health literacy, tidy home