Dengue Fever
HEAD TO TOE ASSESSMENT
PURPOSE
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A Head to Toe assessment is usually done upon admission to a medical facility to look for any current or potential problems.
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PHYSICAL ASSESSMENT
NAME : Krishnaveni A/P Vengatachala
DATE OF ASSESSMENT : 25 / 12 / 2012 ( 2300 hours )
VITAL SIGN * Blood Pressure : 120/70 mmHg * Pulse Rate : 78 bpm * Respiratory Rate : 20 bpm * Temperature : 36 °C * Pain Score : 1 – 2 , side : Chest
GENERAL APPEARENCE : Received lying on bed, conscious and coherent. Pale and has general flushing with rashes.
Reason for admission : complaint cough ++
Admitting diagnosis : Viral fever / acute bronchitis
26 / 12 / 2012 – confirmed diagnosis : Dengue Fever
HEAD TO TOE ASSESSMENT
Area Assessed | Normal Findings | Actual Findings | Remarks | Head | * Round and symmetrical * Smooth, without masses or depressions, nontender. | Round and symmetrical. Smooth,without mass and not tender. | Normal | Hair | * Can be black, brown or burgundy (no evidences of Apolecia), no parasites, and the amount is variable. * Moist, no scars, free from lice and dandruff. | Black, smooth and no presence of parasites. Moist, no scars, no lice and dandruffs. | NormalNormal | Scalp | * Symmetrical, no edema, no involuntary movements. | Symmetrical, no edema, no involuntary movements. | Normal | Face | * Symmentrical or evenly placed and inline with each other. | Symmetrical and nonprotruding. | Normal | Eyes | * Non protruding and equal palpebral fissure. | Symmetrical and nonprotruding. | Normal | Sclera | * White, moist and without lesions. | White, moist and without lesions. | Normal | Conjunctiva | * Shiny,smooth, and pinkor red, absenceof swelling, nolesions and moist. | Shiny, not swelling, palein color. | Decrease RBC count | Nose | * Symmetrically,without
PURPOSE
* -------------------------------------------------
A Head to Toe assessment is usually done upon admission to a medical facility to look for any current or potential problems.
-------------------------------------------------
PHYSICAL ASSESSMENT
NAME : Krishnaveni A/P Vengatachala
DATE OF ASSESSMENT : 25 / 12 / 2012 ( 2300 hours )
VITAL SIGN * Blood Pressure : 120/70 mmHg * Pulse Rate : 78 bpm * Respiratory Rate : 20 bpm * Temperature : 36 °C * Pain Score : 1 – 2 , side : Chest
GENERAL APPEARENCE : Received lying on bed, conscious and coherent. Pale and has general flushing with rashes.
Reason for admission : complaint cough ++
Admitting diagnosis : Viral fever / acute bronchitis
26 / 12 / 2012 – confirmed diagnosis : Dengue Fever
HEAD TO TOE ASSESSMENT
Area Assessed | Normal Findings | Actual Findings | Remarks | Head | * Round and symmetrical * Smooth, without masses or depressions, nontender. | Round and symmetrical. Smooth,without mass and not tender. | Normal | Hair | * Can be black, brown or burgundy (no evidences of Apolecia), no parasites, and the amount is variable. * Moist, no scars, free from lice and dandruff. | Black, smooth and no presence of parasites. Moist, no scars, no lice and dandruffs. | NormalNormal | Scalp | * Symmetrical, no edema, no involuntary movements. | Symmetrical, no edema, no involuntary movements. | Normal | Face | * Symmentrical or evenly placed and inline with each other. | Symmetrical and nonprotruding. | Normal | Eyes | * Non protruding and equal palpebral fissure. | Symmetrical and nonprotruding. | Normal | Sclera | * White, moist and without lesions. | White, moist and without lesions. | Normal | Conjunctiva | * Shiny,smooth, and pinkor red, absenceof swelling, nolesions and moist. | Shiny, not swelling, palein color. | Decrease RBC count | Nose | * Symmetrically,without