Assessment by body system Neurologic: Level of consciousness: No acute distress. Alert and oriented to name, time and place.

Clear verbal response. Motor response equal bilaterally with good grips. Obeys commands and localizes pain. Pupils equal round and reactive to light, and accommodation.( PERRLA) Integumentary: General appearance pale with legs swollen. Tugor is normal with intact integrity. The Mucous membrane is moist and yellowish in appearance. Cardiovascular: Radial pulse palpable and equal bilaterally. Rapid heart rate = 104. S1 and s2 without mumur, rubs, gallop. Skin is flushed with non pitting edema. Capillary refill is less than 3 seconds. Pumonary: Patient have crackles in bilateral bases with decreased breath sounds x4. Respiratory: Normal respiratory rate of 20. Shallow breathing. Patient short of breath while walking. Chest excursion symmetrical. Lung sound audible on all lobes. Sputum is clear and thick. Oxygen saturation is 97%. Gastrointestinal: abdomen soft, tender and sensitive to touch. It is a little enlarged and distended. Bowel sound audible on all 4 quadrant with hypoactive sound. BM once today and small in size with no diarrhea. No nausea and vomiting. Patient has good appetitie and tolerance to preferred diet. Percentage of food eaten is 75%. Genitourinary: Urination independent with 35mL/hr output. The color is yellow and cloudy appearance. Musculoskeletal: Active range of motion. Steady unsteady gait with no deformities. Extremities: He does have 2+ pitting edema bilaterally Psychosocial: Age appropriate behaviou. God mood and judgement.