complex elder SOAP

GENERAL: 68    Yr    old    AA    female Well nourished|Obese
Well Gr, Groomed.Alert    Cooperative Conversant    and    histrionic
EYES:  Lids Normal
Conjunctiva Normalcolor,    no    excessive    redness    no    discharge
PERRLA, EOMs    intact|Glasses    for    reading

ENT: No Hearing Aides,No Decreased Hearing
Oral Mucosa Moist
No Dentures
RESP: Normal Effort
Auscultation Clear.Decreased Breath Sounds    in    both    bases,    no    wheezes    or    rhonchi,    no    accessory    muscle    usename
HR Normal    with    Regular Rhythm    No Murmur.    No Pacemaker
Bilateral Pedal Edema
Pedal Pulses 2+ bilaterally
GI: BS Normal  No Tenderness    No Mass"
M/S: Decreased ROM    in    cervical    spine    area    to    right    and    left    to    30    degrees,    unable    to    stand    due    to    h/o    cauda    equina    Gait Non-Ambulatory|in    wheelchair    as    Aide    Decreased Muscle Strength"bilaterally    lower    extremities
GU:  Foley Cath No    c/o    Tenderness.    No Suprapubic Tenderness
NEURO: Vibration    not    checked Sensation    intake    to    gentle    touch    to    upper    and    lower    extremities.    No Tremors
PSYCH: Oriented to Person/Place/date.
SKIN: No dermatitis.    No Wound|Infection