Patient Assessment — Faadumo Osman
Patient Assessment
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Osman, Faadumo
DOB: 03/14/1961 Age: 63 Sex: F MRN: 2024-7731 PMH: CKD · HTN

Admitted: Today

Unit: Med-Surg 4W

Dx: Acute confusion

Allergies: NKDA

MedChart EHR  |  Nursing Assessment  |  Admission
Vital Signs — On Admission
BP: *Unable to assess — patient combative
HR: 102 bpm
RR: 20 breaths/min
O2 Sat: 96% on room air
Temp: 38.4°C (101.1°F)
General Observations

Appears agitated and purposeful; repeatedly attempts to climb out of bed. Calls staff "gabar," requests her dirac. Does not appear frightened. High fall risk — bed alarm activated. Son present at bedside; requesting female provider for all assessment and care.

System Findings — Abnormals Only

Neuro: Alert but disoriented to place and situation; oriented to person only. Unable to redirect verbally. No focal neurological deficits.
 Cardiac: Tachycardic at 102 bpm, regular rhythm. No murmur. Peripheral pulses intact.
 GU: Urine in brief — dark amber, cloudy, strong odor. Perineal assessment: altered external genitalia consistent with FGM/C — technique adapted.
 Skin: Warm, dry. Mucous membranes slightly dry.
 Pain: Denies verbally — reliability limited given altered mental status.

Great clinical thinking!
You have identified the priority assessment findings on admission. The clinical picture is developing — time to investigate further.
Take card #11
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