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Dengue Fever

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  • Feb. 17, 2013
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HEAD TO TOE ASSESSMENT
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...