Date

Progress Notes

11-10-14
78-yr.-old female, alert, well nourished, with proper posture. Neuro: Oriented to
time,
place, person, and situation. PERRL at 4 mm. Follows commands with hand grips
and
foot pushes strong are strong and equal bilaterally. Pulm.: states I feel short of
breath. Dyspnea present. Breath sounds clear. Respirations even and unlabored.
Mucous
membranes clear. Cardiac: denies chest pain. Patient has edema on both
extremities of the
Hand. . Apical Pulse 108 beats/min., strong and regular. Radial and
dorsalis pedis pulses strong and equal bilaterally. Brisk capillary refill in fingers
and toes.
Negative Homans sign bilaterally. Sequential Compressions used to prevent
clotting
and acquisition of a DVT. Abdomen: states abdominal tenderness. Normoactive
bowel sounds in all four quadrants. Abdomen soft and full. Integumentary:
peripheral
edema in right and left. Palmar and dorsal aspect of the hand at the level of the
metacarpal
head. Skin edges well approximated. No redness of bony prominences.
V.Sanchez, CDU, SN