“My back hurts right where they did the surgery”
Patient with complaints of left posterior rib pain from fractures as well.
Patient reports that he hasn’t been out of bed yet but has sat up with the head of the bed raised.
Blood pressure (mmHg)
Heart rate (beats/min)
Respiratory rate (breaths/min)
Pulse oximetry on 2 L NC (SpO2)
6/10 at back
4/10 at ribs
8/10 at back
5/10 at ribs
5–6/10 at back
4/10 at ribs
Patient supine in bed.
Lines/equipment notable for telemetry, urinary catheter, 2 L O2 via NC, BLE compression stockings, and bilateral sequential compression devices
Head, ears, eyes, nose, and throat (HEENT)
Cardiovascular and pulmonary
Heart sounds: normal S1 and S2 with no murmurs or abnormal sounds noted.
Breathing pattern: notable for diaphragmatic breathing.
Breath sounds: slight decrease in inspiratory sounds in bilateral basilar lung segments anteriorly and posteriorly. No other adventitious sounds noted.
Pedal pulses: 2 + bilateral dorsalis pedis and posterior tibialis.
Range of motion (ROM)
B shoulder flexors and abductors: 4/5 due to pain in back.
B shoulder extensors, adductors, internal rotators, and external rotators: 5/5.
B elbow flexors, extensors, supinator, and pronator: 5/5.
B wrist and hand: 5/5
BLE: 0/5 throughout all muscle groups.
Static unsupported sitting: minimal assistance with BUE support.
Dynamic unsupported sitting: minimal assistance with BUE support.
Standing balance: not appropriate at this time.
BUE: intact to light touch, pain, temperature, and proprioception.
BLE: absent for light touch, pain, temperature, and proprioception.
Trunk: sensation intact until about T6–T7 level, absent distally.
Rolling either direction: contact guard assistance with LE preparation and management; using BUEs, bedside rails, and momentum.
Supine to/from sit: moderate assistance with LE management and trunk.