Patient is alert and oriented to person place and time, flat affect patient is at Eriksons stage of Generativity Vs

stagnation since he is 63 and requires a double assist with ADLs.

Most recent results include T -97.1, P-76, R-18, BP-137/71 ,02 Sat -98 with most pain assessment 3/10 down from 4/10
Facial symmetry with no point of Asymmetry and spontaneously opens eye and obeys commands and color of sclera is
brown with moist eyes. Little mouth odor noted, dysphagia reported, patient buccal cavity is moist and pink in color with no
hearing aids in place.
Hair is dense, no tenting indicative of dehydration, Braden score of 12
Hand grasp equal in strength and muscle, with normal color capillary refill less than 3 secs
Upon Auscultation of heart sounds (S1, S2) at five valve points including point of maximal intensity pulse rate
was 76, regular with a synchronized radial and apical pulse(PMI)
RUL/LUL CLEAR, RLL/LLL with crackles noted bilaterally upon auscultation the lungs