Objective Data General Appearance: Giles looks apprehensive.

Objective Data General Appearance: Giles looks apprehensive. He is sitting up in bed and is clean and well groomed. His spouse is at bedside. He complains of shortness of breath and chest discomfort. Temp: 36.8°C (98.24°F) BP:120/80 mmHg MAP 93 HR: 118 bpm RR: 30 SpO2: 90% on RA NEURO: Alert and oriented to person/place/time/situation. GCS 15. PERRLA. Anxious. CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HR tachycardic. Peripheral pulses palpable and weak x4 at +1. No edema. No murmur RESP: Lung sounds clear in RUL, LUL, RML and basilar crackles in RLL and LLL. No stridor. Respirations are symmetrical and labored. GI: Abdomen obese. Soft, non-tender. NABS x4. Last BM was today. Negative for nausea and vomiting. GU: Voids painlessly and without hesitation. Clear, yellow urine. UA normal. Musculoskeletal: Moves all extremities with no overt deficits. Ambulates unassisted but is slow paced. Equal grip strength bilaterally. Integumentary: Skin is warm, dry, and intact. No bruises or wounds noted. Psychosocial: Broad affect, apprehensive. Wife at bedside for support. Clinical significance/ impact ? SCIENCE HEALTH SCIENCE NURSING NUR NUR258

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