Both clients report this type of discipline as being

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clients report this type of discipline as being miserable and that they inherited this from their parents. No physical or mental abuse of concern. Review of Systems: HEENT:No loss of vision or hearing. No sign of congestion, sore throat, or runny nose. SKIN:Cool and dry skin with no signs of wounds or lesions. CARDIOVASCULAR:No complaints of chest pain, tightness, discomfort or palpitations. S1, S2 heard upon auscultation. 2+ pedal and radial pulses. No weight gain and no edema. RESPIRATORY:Clear lung sounds with no adventitious sounds. No rhonchi or wheezes auscultated, and chest is symmetrical. No cough present. GASTROINTESTINAL:No nausea, emesis, or diarrhea. Abdomen soft, no distention, no discomfort on palpation. Bowel sounds present in all four quadrants. GENITOURINARY:No burning or discomfort when urinating. NEUROLOGICAL:No double vision, headaches, seizures. No loss of memory. Alert and oriented x person, place and time. Agitation present in male client. MUSCULOSKELETAL:No joint or muscles pain. No generalized weakness. HEMATOLOGIC:No signs of bleed, no history of anemia. No dizziness or lightheadedness upon standing.
LYMPHATICS:Lymph nodes normal in size on palpation. No history of splenectomy. PSYCHIATRIC:“Needs to be added to” ENDOCRINOLOGIC:No history of diabetes. Fatigue noted. No heat or cold intolerance. No brittleness of skin and hair noted. Physical Assessment: Vital signs: BP: 145/89, Pulse: 104, Resp: 22, Temp: 97.9, Oxygen Saturation 92% on RA, Neck: Negative jugular vein distension. Chest/Lungs: Clear and with no crackles, rhonchi or wheezing. Thorax symmetrical. Heart/Peripheral Vascular: S1, S2, and S3 heart with no murmur present, pulses+2 bilateral pedal and +2 radial pulses. ABD: Abdomen soft and nondistended, regular bowel sounds heard in all 4 quads.

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