GFB

Room: F1

Date of Admission: March 22, 2018

► Vital Signs

Temperature: 39.1 C (left axilla)

Cardiac Rate: 125 beats/minute (Apical)

Pulse Rate: 130 beats/minute (radial, +3 = bounding)

133 beats/minute (dorsalis pedis, +3 bounding)

122 beats/minute (temporal, +3 bounding)

139 beats/minute (carotid +3 bounding)

Respiratory Rate: 19 breaths/minute = abdominal breathing + abdominal muscle spasms

on expiration (?) (basta daw ga shake ang sa sides sang abdomen ya
kung mag expiration… idk ang chakto na term)

Blood Pressure: 110/70 mmHg

PaO2: 94%

► GCS 9
Eyee Opening 3 To speech
Verbal Response 2 Incomprehensible sounds
Motor response 4 Withdraws from pain
► Contraptions
o IVF at right PNSS 1L at 40cc/hr
o BT at left packed RBC (3rd transfusion) B+
o Nasal prongs at 2L/min
o NGT tube with coffeeground (brownish, water) drainage at left nares
o Urinary catheter draining to urobag of turbid, light yellow urine
o Pulse oximeter probe at left index finger
► Inspiratory stridor heard maximally at anterior right upper chest
► Inspiratory and expiratory stridor heard over posterior upper chest wall
► 9cm diameter mass, firm, demarcated, hard but slightly movable nontender, warm with 1cm
hypertrophic scar at center occupying the left superiorclavicular triangle (just above clavicle)
and some parts of lower posterior triangle, no drainage, soft pulse heard upon auscultation, no
bruit
► Dry hacking cough (+)
► Extremities warm to touch but facial area is cold and clammy
► Short hypoactive bowel sounds of 2cycles/min
► Abdomen no mass or tenderness
► (+) Abdominal aorta pulse +2