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Admitted for chief complain of

S- O Fever OCough ODyspnea


O Headache O Dizziness Opain
O Urine output, OBowel
movement x day
O Weakness O Fatigue
Appetite O Nausea Ovomiting
Obleeding
O- Awake, IRD, Coherent, oriented
Icteric Schlerae, Palpebral
Conjunctiva, PERRLA
O CLAD O discharges
ECE, BreathSounds ,O Crackles
dynamic Precordium,
Rate,Rhythm OMurmur
Osoft Odistention
active bowel
sounds, Otenderness
Pulses
CRT <2sec, Oedema

AP-Continue meds
Continue V/S monitoring

Admitted for chief complain


of
S- O Fever OCough
ODyspnea
O Headache O Dizziness
Opain
O Urine output, OBowel
movement x day
O Weakness O Fatigue
Appetite O Nausea
Ovomiting
Obleeding

O- Awake,IRD, Coherent,
oriented
Icteric Schlerae, Palpebral
Conjunctiva, PERRLA
O CLAD O discharges
ECE, BreathSounds ,O
Crackles
dynamic Precordium,
Rate,Rhythm
OMurmur
O soft
Odistention active
bowel sounds, Otenderness
Pulses
CRT <2sec, Oedema
AP-Continue meds
Continue V/S monitoring
Health Advise

Admitted for chief complain of


S- OFever

OCough ODyspnea

Headache Dizziness pain


Urine output,

Bowel movement x day

O Weakness O Fatigue
Appetite O Nausea Ovomiting
Obleeding
O- Awake,

IRD, Coherent, oriented

Icteric Schlerae, Palpebral Conjunctiva, PERRLA


O CLAD O discharges
ECE, BreathSounds ,O Crackles
dynamic Precordium,

Rate,Rhythm

OMurmur

O soft

Odistention active bowel sounds, Otenderness

Pulses

CRT <2sec, Oedema

AP-Continue meds
Continue V/S monitoring
Health Advise

Admitted for chief complain of


S- (-) Fever

(-)Cough (-)Dyspnea

(-) Headache (-) Dizziness (-)pain


(-) Urine output,

(-)Bowel movement x

day

(-) Weakness (-) Fatigue


Appetite (-) Nausea (-)vomiting
(-)bleeding
O- Awake,

IRD, Coherent, oriented

Icteric Schlerae, Palpebral Conjunctiva, PERRLA


(-) CLAD (-) discharges
ECE, BreathSounds ,(-) Crackles
dynamic Precordium,
(-) soft
Pulses

Rate,Rhythm

(-)Murmur

(-)distention active bowel sounds, (-)tenderness


CRT <2sec, (-)edema

AP-Continue meds
Continue V/S monitoring
Health Advise

Admitted for chief complain of


S- (-) Fever

(-)Cough (-)Dyspnea

(-) Headache (-) Dizziness (-)pain


(-) Urine output,

(-)Bowel movement x

day

(-) Weakness (-) Fatigue


Appetite (-) Nausea (-)vomiting
(-)bleeding
O- Awake,

IRD, Coherent, oriented

Icteric Schlerae, Palpebral Conjunctiva, PERRLA


(-) CLAD (-) discharges
ECE, BreathSounds ,(-) Crackles
dynamic Precordium,
(-) soft
Pulses

Rate,Rhythm

(-)Murmur

(-)distention active bowel sounds, (-)tenderness


CRT <2sec, (-)edema

AP-Continue meds
Continue V/S monitoring
Health Advise

Admitted for chief complain of


S- (-) Fever

(-)Cough (-)Dyspnea

(-) Headache (-) Dizziness (-)pain


(-) Urine output,

(-)Bowel movement x

day

(-) Weakness (-) Fatigue


Appetite (-) Nausea (-)vomiting
(-)bleeding
O- Awake,

IRD, Coherent, oriented

icteric Schlerae, Palpebral Conjunctiva, PERRLA


(-) CLAD (-) discharges
ECE, BreathSounds ,(-) Crackles
dynamic Precordium,
(-) soft
Pulses

Rate,Rhythm

(-)Murmur

(-)distention active bowel sounds, (-)tenderness


CRT 2sec, (-)edema

AP-Continue meds
Continue VS monitoring
Health Advise