WEEK 3 MANAGEMENT PLAN HEENT IHUMAN

Week 2 I human
ROS
General: Denies weight patient well nourished “OBESE OR THIN UNDERNOURSHIED IF
PATIENT IS” well dressed, no unusual gestures or ticks, denies any weight changes , fatigue or
fever, CHILLS NO CHANGE IN SLEEP HABITS
HEENT: normocephalic/ atraumatic, PEERL, no eyes no irritation, no redness, pupil are
equally round and reactive to light, no pain, no diplopia, no floaters, no blurred vision, no
cataracts, nose without masses, lesions or deformities. throat Oral pharynx pink mucous, no sore
throat ears no tinnitus no earaches no problems hearing ear are symmetric to face.
Neck: supple, no JVD, lymphadenopathy or bruit, symmetric, no lesions, no swelling, no
difficulty swallowing
Breast: n/a
Respiratory: lungs clear to auscultation bilaterally with normal with normal respiratory effort
no difficulty breathing nose is medial no swelling or deviation, no issues with smelling
Cardiovascular/Peripheral vascular: denies chest pain, no palpitations, no hx of murmur no
rubs or gallops capillary refill <2seconds, radial pulses 2+
Gastrointestinal: abdomen soft, nondistended, non-tender, bowel sounds active x 4 quadrants,
no nausea or vomiting no reflux no rebound pain, no changes in bowel and bladder. he takes a
Colace daily.
Genitourinary: no changes in urinary patterns dysuria or incontinence he is heterosexual. no
history of STD’s he is no longer sexually active.
Musculoskeletal: pt has a fractured ankle as a child. No other broken bones
Psychiatric: affect is appropriate no history of suicide or anxiety or depression but sated he was
after his wife died but nothing out of the ordinary
Neurological : cranial nurses II-XII grossly intact no focal neurologic deficits, no dizziness, no
altered level of consciousness , no numbness, weakness, paresthesia, no headaches, some
memory changes (age), no gait disturbances, no abnormal movements noted.
Skin: this noted rash like cherry red raised papules on his torso (chest to waist) looks to
approximately 50 or more noted, varying in size and shape no itching soreness or exudate noted
the are about 0.5mm in size in majority. Good turgor, no pitting edema noted,
Hematologic: no known allergies to food or seasonal allergies
Endocrine: no diabetic history no polyuria no polydipsia
Allergic/immunologic: n/a