How to put this physical assessment in Narrative Form? 68 yrs old F, no known allergies, full code, patient diagnoses: left-side hematoma on forehead, subdural hematoma, and mechanical fall. Objectives: BP= 144/54, RR=18, PR=52, RA=97%, Temperature =98.3, input=240ml, output=voided 1, patient has left side hematoma on forehead, sacral pressure ulcer on left buttcheek, lesion on lower right leg, calcified mass on right side of torso, alteration in level of consciousness, A&O × 1, screams and cries when touched on the left arm:Subjective data patient states that it hurts to be touched on or lay on her right side
Physical examination is a process of comprehensive examination to check the health status of an individual and to identify any abnormalities at the ear lies.
Name: Mrs.X
Age: 68 years
Sex: Female
Diagnosis: left-side hematoma on forehead, subdural hematoma, and mechanical fall.
Vital signs: T- 98.3 deg F
P- 52 beats /mt
RR - 18 breaths/mt.
BP - 144/54 MM Hg
Allergic history : Nil
Level of consciousness: altered
Pain: Pain of severe intensity over the left arm and patient states it hurts by touch.
Head: Inspection: Left: Hematoma on forehead
Back: Inspection : sacral pressure on left buttcheek
Lower extremity : Lesion on lower right leg
calcified mass on right side of torso.
How to put this physical assessment in Narrative Form? 68 yrs old F, no known allergies,...