- HR 64/min
- RR 18/min
- 100% on RA
Constitutional: Appearance: Normal appearance.
HENT: Extraocular movements intact. Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light. Neck: Normal range of motion.
Cardio: Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds.
Pulmonary: Normal breath sounds.
General: Bowel sounds are normal.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness.
Comments: Mobile semi-rigid/deformable mass in middle UQ of abdomen
Skin: General: Skin is warm and dry. Well healed surgical scar R knee
Findings: Bruising present.
Neurological:General: No focal deficit present.
Mental Status: He is alert and oriented to person, place, and time.
Sensory: Sensation is intact.
Motor: Motor function is intact.
Deep Tendon Reflexes: Reflexes are normal and symmetric.
Mood and Affect: Mood normal.