Translation

64 year old female presented with nausea and vomiting . No acute events overnight,  nausea or vomiting. No shortness of breath or chest pain.


Physical Exam
Alert and oreinted to person, place and time
Cardiac- Regular rate and rhythm, no murmur, rub or gallop
Lungs- Clear to asuculattion bilaterally
Abdomen- soft non tender non distended

Assessent and Plan

64 year old female with partial samll bowel obstruction.

Nasogastric tube to low intermittent suction
Nothing by mouth
Intraevenou fluid