Michael Smith is an 18-year-old African American male who presents to your floor after repair of his right anterior cruciate ligament (ACL).

PMH:

Denies medical history
Previous tonsillectomy at age 5 due to recurrent strep infections. No complications from that procedure.
Family history positive for lung cancer in maternal grandfather.

HPI:

Michael is an 18-year-old high school senior who tore his right anterior cruciate ligament (ACL) playing soccer. Earlier today at 1000, he underwent an ACL repair under general anesthesia and will stay overnight in your facility. He will work with physical therapy to learn crutch walking, and the plan is to discharge him to home tomorrow. Provider orders allow for partial weight-brearing on the RLE as tolerated.

Michael has not been out of bed since surgery.

1500 Shift Assessment:

Vital signs: Temp 98.6 F, HR 74 bpm, RR 16 breaths/min, BP 120/74, SaO2 99% room air
General: Appears stated age; speech clear; c/o feeling “tired”; denies pain
Skin: warm and dry; appropriate skin tone for race; no evidence of pressure injuries
HEENT: Noncontributory
Respiratory: lungs clear to auscultation bilaterally (CTAB); denies cough.
Cardiovascular: S1 and S2 auscultated, no murmurs present. Denies chest pain.
Gastrointestinal: bowel sounds auscultated in all quadrants; abdomen soft and nontender; denies nausea
Genitourinary: Denies dyruria; last void was 2 hours ago
Musculoskeletal: Surgical incision is covered by a large pressure dressing. Immobilization brace is present. Strength 5/5 in all joints except right knee strength and ROM not assessed.
Neurological: alert and oriented x 4; PERRLA; denies numbness and tingling in right lower extremity

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