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General Appearance

• Patient R.A. appears tired & weak but not that critically ill
person. He is thin for his age of 20 y/o. He stayed on bed, either
in supine or semi-fowler’s position. He often looks drowsy and
sleepy and whenever he feels something painful, he shows facial
grimace and sigh. He is oriented to time, place and person;
coherent and answer questions appropriately.

Vital Signs
• Patient R.A.’s vital signs monitored Q4H except for post blood
transfusion which is monitored Q15min. for the first hour, Q30min.
for the next hour and then QH. As of August 17, 2010 during the
6am-2pm shift, his temperature was at 37.4ºC taken @ right axilla,
afebrile and within the normal range during the entire shift. His
pulse at 92bpm palpated @ left radial pulse. He breathes
spontaneously to room air @ 23cpm, within normal rate, depth and
rhythm and his blood pressure of 100/60 mmHg.

Integumentary
• Patient’s skin is brownish, warm to touch and with pale lips
noted. Patient has good skin turgor, assessed in left forearm. No
presence of skin lesions, incisions and bruised noted. Patient
doesn’t experience itchiness in the skin.
Cardiovascular System
• Patient has ongoing mainline IVF bottle #2 D5LR 1L regulated @ 15
gtts/min with remaining amount of 650cc infusing well @ left
metacarpal vein & side drip bottle #2 PNSS 1pint interrupted.

Upon assessment, no chest pain noted, He had good capillary


refill of less than 2 seconds.

Significant findings were noted with a decrease in his RBC, Hct


and Hgb count in the CBC result. Patient has an ongoing blood
transfusion of 1 packed RBC O+ and completed around 8:00am.
Another 2 units of packed RBC was transfused on the same day with
blood type O+; Kept monitored. Patient was stable during blood
transfusion. No fever, DOB, urticaria, rashes noted.

Respiratory
• Patient breathes spontaneously to room air within normal range. He
has a respiratory rate of 23cpm and has a clear breathe sound
heard in both lung fields upon auscultation. Patient R.A. had a
chest x-ray done without significant findings noted.

Chest
• Chest size is equal and symmetrical. No mass noted upon palpation.

Abdomen
• Flat abdomen and no abdominal distention upon palpation.
Gastrointestinal Tract
• Prior to admission, patient has good appetite and had no history
of constipation, incontinence and sometimes he had episodes of
diarrhea.

Upon admission, patient is on diet as tolerated and


eventually placed on soft diet; consumes only 3/4 of his entire
served meal in a day. Patient is on increase fluid intake to
replace fluid loses. He defecate once a day to a dark red loose
stool with clots and mucous. He does not experience any pain
when defecating.
Genito-urinary tract

• Prior to admission, patient sometimes complained of having


noctoria. His urine output was within normal limits.

Upon admission, the physician ordered for a strict MIO of


an hourly monitoring of his intake and output. He had a foley
catheter attached to urine bag patent and draining well to dark
yellow urine at the range of 150-300 cc/hr. No pain, burning
sensation upon urination and no bladder distention. Patient’s
BUN= 3.16 mmol/L and creatinine= 70.72 mmol/L; within normal
range.
EENT

• Upon inspection, patient’s eye, ears, nose, throat were of


normal shape and symmetry. Slightly pale conjunctiva. No
presence of any inflammation and no yellowish discoloration of
the eyes. Pupils Equally Round and Reactive to Light and
Accommodation. No pain, swelling lesion, ear discharges noted No
nasal discharges and tenderness noted.

Musculoskeletal

• Prior to admission, patient often complained of muscle and joint


pain especially after his ROTC class.

Upon assessment, patient is weak as observed. He was able


to move both upper and lower extremities with assistance.
Neurologic

• Patient upon assessment is awake and conscious lying on bed in


supine position but looks tired. He is coherent, oriented to
time, date, place and person. He is responsive to both verbal
and nonverbal stimuli. He obeys command properly.