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Vital Signs:
Height: 5’8” Weight: 154 pounds BMI: 23.4 BP: 132/76 P: 76
regular R: 16
HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts noted; poor dentition.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
LUNGS: Respirations are unlabored, decreased breath sounds and crackles at the bases bilaterally. Prolonged expiratory phase throughout lung fields, inspiratory wheezes and a productive cough of cloudy white sputum.
HEART: RRR with regular without S3, S4, murmurs or rubs.
ABDOMEN: Round, firm abdomen; active bowel sounds; non-tender.
NEUROLOGIC: Unsteady gait, swaying while standing during periods of agitation. Achilles reflexes are present bilaterally. Strength is equal but decreased in the upper and lower extremities bilaterally.
GENITOURINARY: Urinary incontinence with strong odor of urine. NO CVA tenderness.
MUSCULOSKELETAL: Mild kyphosis. Heberden’s nodes at the distal interphalangeal joints (DIP) of all fingers, and marked crepitus of the bilateral knees on flexion and extension. Pedal pulses palpable. No edema noted in lower extremities.
PSYCH: Manic, restless, angry and hyperverbal
SKIN: Right forearm with 3 cm x 5 cm x 0 cm dry, scabbed abrasion. Left forearm with 4 cm x 5 cm x 0 cm dry, scabbed abrasion.
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