Head to toe Assessment

September 22,2021 @ 8 am

General:
Weight: 130lbs
Vital Signs:
BP: 80/50mmHg
T: 39.0 degree celcius
RR: 25 cpm
PR: 134bpm
O2 Saturation: 94%
Extremities:
edema at right upper arm
bipedal edema
Skin:
poor skin turgor
hot flushed skin

Physical Examination:
Nuerologic:
- Diaphoretic

Musculoskeletal:
- chills with low back pain, generalized body weakness ,
appeared restless

Cardiovasucular:
Day 2 Blood GSCS
ECG: Atrial Fibrillation to Supra Ventricular Tachycardia
-paitent complained of chest pain (pain scale: 8/10),

Urinary:
-discontinued HD at RDU
-Na: 140.5

GI:
-nausea
BUN: 6.24

1 pm

Vital Signs: T: 38.5 celcius

CR: 132 bpm
BP: 80/50mmHg
Musculoskeletal:
K: 4.13

Metabolic:

Creatinine: 710
Hematologic:
Hgb: 95

Cardiovascular:
Hematocrit: .34

September 23, 2021 @ 7 am

General:
Vital Signs:
BP: 100/60 mmHg
O2 Saturation: 97%

Neurologic:
awake, coherent
comfortable on bed

Musculoskeletal:
Complained more of back pain

GI:
LBM x 4

Cardiovascular:
Day 3 Blood GSCS with result

September 24, 2021 @ 7 am

General:
Vital Signs:
BP: 110/90mmHg
O2 Saturation: 97%

Nuerologic:

GCS: 15
Musculoskeletal:
K: 3.20

Metabolic:
Creatinine: 900
FT3: 2.50

September 25, 2021 @ 7 am

Neurologic:

GCS: 15

12 noon

Nuerologic:

-GCS: 15

Urinary:

-HD tolerated

September 22, 2021

-Taken in poor inspiration shows no active parenchymal infiltrates.

-Heart is magnified.
-Trachea is at the midline.
-Right hemidiaphragm is elevated.
-Right CP sulcus is blunted by cardiac shadow. (Di ko sure as ani dapit or apil pa ba)

(Mar patan- aw ko unsay ubang dapat buhaton or usabon ba dili ko sure jud ani sa uban thanks.
Pabutang lang dir)