Objective/Exam Elements
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GENERAL: No acute distress. Obese, thin. Pt sitting, laying.

HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Ear and nose - no erythema or exudate.
Dentition intact. Throat, clear, moist, no erythema or exudate.

NECK: No apparent thyromegaly, no cervical lymphadenopathy.

LUNGS: Quiet, unlabored respiration. No dullness or tenderness. Clear to ascultation b/l. No rales, ronchi, or wheezing. NASAL CANNULA___

CV: No apparent JVD. No bruits. RRR. S1/S2 wnl. No murmurs, rubs, or gallops.
Peripheral pulses 2+. No edema, clubbing or cyanosis. Capillary refill <2 sec.

ABD: OSTOMY, WOUND, DRAINS.
Soft, nondistended, nontender. + bowel sounds in all 4 quadrants. No apparent hepatosplenomagly. No CVA tenderness.

GU: Foley + or =. Scrotum, penis.

NEURO: AOX3. CN2-12 intact. Normal muscle bulk and tone. Strength 5/5 and sensation intact throughout. DTR 2+ and symmetric. Cerebellar testing intact.

SKIN: No lesions or rashes.
Wound size, color, drainage.

MSK: No joint erythema, swelling, or tenderness. Active ROM intact throughout. Normal gait.

EXTREMITIES: No edema, clubbing or cyanosis.

LINES: PICC, DRAIN, IV
Central lines
Vent - vent settings
GENERAL: No acute distress. Obese, thin. Pt sitting, laying.

HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Ear and nose - no erythema or exudate.
Dentition intact. Throat, clear, moist, no erythema or exudate.

NECK: No apparent thyromegaly, no cervical lymphadenopathy.

LUNGS: Quiet, unlabored respiration. No dullness or tenderness. Clear to ascultation b/l. No rales, ronchi, or wheezing. NASAL CANNULA___

CV: No apparent JVD. No bruits. RRR. S1/S2 wnl. No murmurs, rubs, or gallops.
Peripheral pulses 2+. No edema, clubbing or cyanosis. Capillary refill <2 sec.

ABD: OSTOMY, WOUND, DRAINS.
Soft, nondistended, nontender. + bowel sounds in all 4 quadrants. No apparent hepatosplenomagly. No CVA tenderness.

GU: Foley + or =. Scrotum, penis.

NEURO: AOX3. CN2-12 intact. Normal muscle bulk and tone. Strength 5/5 and sensation intact throughout. DTR 2+ and symmetric. Cerebellar testing intact.

SKIN: No lesions or rashes.
Wound size, color, drainage.

MSK: No joint erythema, swelling, or tenderness. Active ROM intact throughout. Normal gait.

EXTREMITIES: No edema, clubbing or cyanosis.

LINES: PICC, DRAIN, IV
Central lines
Vent - vent settings

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