Vital Signs :
•Temp: 36.5°C
Abdominal Assessment findings:
•Abdomen soft and non-tender
•Bowel sounds present
Neurological assessment findings:
•LOC: A&O x3
•PERRLA
•Gait normal
•Motor and sensory function intact
BGL level:
4.7 mmol/L
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Vital Signs:
•BP: 170/100 mmHg
•HR: 118 bpm
•RR: 24 bpm
•Sp02: 94% on 2Lvia NP
Cardiac assessment findings
•Cardiomegaly on CXR
•JVP elevated
•PMI displaced laterally
•S3 heart sound
•Murmur over mitral valve
Respiratory assessment findings:
•Dyspnoeic
•Increased work of breathing
•Bibasilar crackles on auscultation
•Patient producing pink-tinged frothy sputum
Neurological assessment findings:
GCS: 14
•Eye opening 4
•Verbal response 4
•Best motor response 6
Subjective cues :
uprovoking factors: exercise Palliative factor: rest and sitting up and using several pillows at night to sleep.
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Q:
pressure in chest when breathing
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R:
All over chest anterior and posterior. Not radiating.
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S:
about 5/10
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T:
progressively getting worse. Symptoms of shortness of breath are always there but get worse or better depending on activity or position
Fluid Assessment findings:
Peripheral pulses are difficult to palpate
•Presence of pitting edema bilaterally
•Capillary refill - 5 seconds
•Current weight 97kg (baseline weight 94kg)
•Raised JVP
•Output since midnight: 200ml; Input since midnight: approx 1672 mL (oral and IV)
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