VITAL SIGNS
BP: 140/ 70, HR: 84, RR; 20, O2 sat 100%, weight: 192 lbs , Height: 5’10” BMI 27.5
General Appearance: sedated and intubated young male
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Respiratory: decreased breath sounds with rales at the right lung base
Abdominal: soft mildly distended abdomen, slightly decreased bowel sounds. PEG tube site appears clean and dry. External bumper is at 4 cm , loose and lightly touching the skin. The tube freely rotates in the tract. No ascites, hernias or organomegaly appreciated
Extremities: warm and well perfused extremities, 1+ bilateral pitting edema to shins bilaterally
Neurologic: minimal response to painful stimuli
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