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1. REPORT WRITING.
PATIENT DETAILS DIAGNOSIS, TREATMENT & 24HOURLY REPORT.
NAME : KNAXX ANTWISON
AGE : 28years
ADDRESS : Bekwai
PATIENT No : 000112233
T.O.A : 12pm
TEMP : 37
PULSE : 80b/m
RESP : 20c/m
BP : 120/80mmHg
WT : 60kg
DATE : 25/6/2017
NIGTH REPORT
NAME : KNAXX ANTWISON
AGE : 28years
ADDRESS : Bekwai
PATIENT No : 000112233
TEMP : 36
PULSE : 84b/m
RESP : 24c/m
BP : 110/80mmHg
MALARIA.
Client came to the ward to be admitted after been seen through the OPD in a
weak but conscious state. A comfortable bed was made for him, On arrival vital
signs was checked and recorded as T – 37, P – 80b/m, R – 20c/m and Bp –
120/80mmHg. An iv cannula was secured on clients right hand and IVF N/S
500mls setup and dripping. IM diclofenac 75mg and IV Artesunate 120mg
administered as a Stat dose. Client has been reassured and made comfortable in
bed. His condition is fair. At 2pm vital signs was checked and recorded as T –
36.0, P – 80b/m, R – 20c/m and Bp – 120/80mmHg. At 6pm vital signs was
checked and recorded as T – 35.5, P – 80b/m, R – 20c/m and Bp – 120/80mmHg.
He has eaten and has observed his personal hygiene. FA. Signed
Client had a comfortable sleep throughout the night without any new complaint
at 10pm yesterday vital signs was checked and recorded as T – 36.0, P –
80b/m, R – 20c/m and Bp – 120/80mmHg.Tab P`mol 1g administered. At 12am
IV Artesunate 120mg was administered as a repeated dose. This morning client
is awake and oriented. He is doing well and responding to treatments given, vital
checked and recorded as T – 36.0, P – 84b/m, R – 20c/m and Bp – 110/80mmHg.
Tab P`mol 1g administered, IVF N/S 500mls setup and dripping. He has observed
his personal hygiene and has eaten. He been reassured and made comfortable in
bed awaiting to be reviewed by M.O FA. Signed