8.4: Sample Documentation
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Patient denies chest pain or shortness of breath. Vital signs are within normal limits. Point of maximum impulse palpable at the fifth intercostal space of the midclavicular line. No lifts, heaves, or thrills identified on inspection or palpation. JVD absent. S1 and S2 heart sounds in regular rhythm with no murmurs or extra sounds . Skin is warm, pink, and dry. Capillary refill is less than two seconds. Color, movement, and sensation are intact in upper and lower extremities. Peripheral pulses are present (+2) and equal bilaterally. No peripheral edema is noted. Hair is distributed evenly on lower extremities.
Patient reports increase in breathing difficulty and increased swelling of bilateral lower extremities over the last three days. Diminished pulses (+1) bilaterally and pitting edema (+2) in the bilateral lower extremities. Upon auscultation, an S3 heart sound is noted and the patient has bilateral crackles in the posterior bases of the lungs. Skin is pink, warm, and dry with capillary refill of < 2 seconds. All other pulses are present (+2), and no other areas of edema are noted. JVD is absent.