C10002643 / invoice 10000

Reason: Can't Walk This MorningHISTORY:Current meds:Prophylaxis:Pre-existing conditions:Access to toxins eg. Rodenticide:TRIAGE:HR:RR:Temp:Mm: Crt:Mentation:EXAMINATION:Body Condition Score: Pain Scale (0-4):Hydration status (%):Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  - Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFPROBLEM LIST:DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:DIAGNOSTICS:ASSESSMENT:TREATMENT:PLAN:CLIENT COMMUNICATION:Blood Gas Analysis Results - source:Findings:Interpretation:Bloods were taken for in-house testing:- Please find attached to the patient record.> Biochemistry- Significant findings:Bloods were taken for in-house testing:- Please find attached to the patient record.> PT (11-17): > APTT (71-102): - Significant findings:Interpretation:    Vital Signs