Name: GRT Chief Complain: Abdominal Pain Age: 4 y/o
Diagnosis: Wilms TumorSex: Male Attending Physician:
Dr. IDate and time P.A done: Jan. 21, 2010; 9 AM Height : 99 cmWeight: 13 kg
On sitting position, awake, moaning, oriented to person, time, andplace, ambulatory, appropriately dressed and neat in appearance. Appears to be skinny.Complained of pain, facial grimace noted graded with a score of 8/10 with 10 being themost painful and 0 as no pain. With IVF of D5IMB 500 cc x 24 cc/hr attached at right cephalic vein, patent and infusing well. Vital signs revealed: Temp: 36.3 degree CelsiusPR: 112 bpm RR: 24 bpm BP: 110 / 90 mmHg.
Skin is dark brown in color, uniform to all parts of the body except for the palmsof the hand and the soles of the feet. Excessive sweating noted. Scar noted at 5cm inlength on the right anterior forearm, and 7cm on the left brachial area. Intact, cold andclammy to touch. Has good skin turgor of two seconds when pinched .
Nail beds are pinkish. No yellowish discoloration noted. With dirty anduntrimmed free edges. Absence of clubbing. Smooth in texture with intact surroundingtissues. Convex in curvature with an approximate angle of 160 degrees. With goodcapillary refill of 2 seconds upon blanched test.
Terminal hairs are evenly distributed on the scalp, with short and slightly curvedendings, black in color, absence of infestations noted. Shiny, oily and smooth in texture.
Color is lighter than facial skin, absence of dandruff, lesions, scars and anyinfestations noted. Intact and smooth in texture. Absence of masses or lumps noted.
Normocephalic, size is proportionate with the body. Presence of scar on botheyebrows about 3 cm in diameter. With head circumference of 49 cm, with absence of lumps and masses. With palpable temporal pulse, frontal and occipital prominences.
In midline position of the body, in full range of motion... [continues]
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