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HISTORY AND PHYSICAL Spiritual Not able to discuss at this time Sleep habits Reports poor, awakens frequently at night Nausea/Vomiting Denies Physical Vital signs Blood pressure: 148/76, heart rate: 115, respiratory rate: 32, temperature 37.0° C (98.6° F), oxygen saturation: 96% Neurosensory Oriented to time, person, and place Head and neck No redness, edema, visible abnormalities, report of occipital lobe headache and pain of 2/10 Cardiac and peripheral vascular Heart rate and rhythm regular, no murmurs, pulses +2 equal bilaterally, report of chest pain of 2/10 over mid to lower sternum Respiratory Respirations shallow and labored, lung sounds clear bilaterally to auscultation Gastrointestinal Abdomen soft, nontender, bowel sounds present in all 4 quadrants Musculoskeletal Gait steady, denies pain Skin Pink, warm, diaphoretic General appearance Appropriate, clean appearance MEDICATION ADMINISTRATION RECORD Order Date Stop Date Scheduled Medications 0700-1900 1900-0700 02/14/XX Paroxetine (Paxil) 20 mg PO daily Ortho Tri-Cyclen 1 tablet PO daily 02/14/XX MEDICATION ADMINISTRATION RECORD 02/14/XX 02/14/XX PRN Medications Ibuprofen (Motrin) 600 mg PO every 6 hr PRN mild pain MOM 30 ml PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at bedtime PRN sleep difficulty 02/14/XX IV Therapy Electronic Signature Date Name
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