Physical fierce

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 auscultation 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, non-distended, non-tender. + bowel sounds in all 4 quadrants. No apparent hepatosplenomegaly. 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