DRAFT PATIENT NOT YET SEEN

PLEASE DO NOT FOLLOW PLANS

Age/gender
DA:
ADL I COMM A
Non smoker
Non drinker
Works as:
Stays with:
Nil travel hx
Nil contact hx
No contact with known / suspected COVID cases
Denies visiting COVID clusters

PAST MEDICAL HISTORY

Last admission:

CURRENT ADMISSION
HOPC
ED CLERKING
1.

HISTORY REVISITED IN THE WARD

1.

INITIAL EXAMINATION FINDINGS

VITALS
IN ED:

IN WARD:

O/E
Alert comfortable
GCS15, conversant coherent
Non toxic, not in respiratory distress
(speaking in full sentences)
Tongue moist
(JVPNE)
Heart s1s2 (nil murmur)
Lungs: clear, nil creps / wheeze heard
Abdo: soft non tender, not distended, bowel sounds present
(murphy’s neg, renal punch neg bilaterally, no guarding / peritonism/ rebound)
Calves supple, non tender
No peripheral oedema

(Neuro)
PEARL, 3mm
EOM full, nil nystagmus
No facial droop / asymmetry / numbness
Hearing grossly intact
Tongue central

Power: UL, LL
Reflexes: UL, LL
Babinski:
Sensation grossly intact

No pronator drift
No dysmetria / dysdiadochokinesia

(Falls)
No cephalohematoma
No periorbital bruising
Chest and pelvic compression negative
No spinal tenderness / step deformity
No long bone tenderness
No limb length shortening

INITIAL INVESTIGATIONS
h/c
FBC RP LFT CRP Procal Lactate

CXR:

IN ED:
Blood cultures done
IV Rocephin given
CT brain done

IMPRESSION

PLANS
Q2h paras x4 + SpO2, then q4h if well
Keep SpO2 < 94% vs 88-94%
Strict I/O charting
NBM / Allow diet (DOC vs DM low fat low salt renal diet)
H/C TDS + 10PM +/- SCSI
(GCS / CLC charting q4h, vomit / stool / hemoptysis chart, fits chart, neurovascular chart)
(PVRU once, fall precautions, fluid restrict 1L/day)
Monitor for: GCS drop /drowsy/lethargic, chest pain / dyspnea / desat, melena/PR bleeding

Renal review cm for dialysis support

KIV update CVM cm

CXR ECG if not yet done

Add test: CMP, cardiac enzymes
Blood cultures
UFEME, urine cultures
Trend FBC RP cm

Analgesia (vs symptomatic treatment)

Hold off antibiotics for now vs antibiotics: IV Rocephin, IV flagyl
IV drip HM 1L/24h
Med recon, restart old meds, (withhold antiHTN/diuretics, blood thinners/antiplt, OHGA)

Inform doctor if: T > 38, HR > 110 or < 50, BP > 180 or < 90, SpO2 < 94%
If T> 38, for full septic work up incl. blood cultures, UFEME, urine cultures, and cover with antibiotics