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... [continues]

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