Vital signs: on initial physical examination his weight was 104. 6 Kg which was down from 113. 2 Kg on the day he was admitted. Height was 175. 6 Cm; temperature was 102. 9 Fahrenheit which was higher than his admitted temperature of 96. 9. His pulse rate was 121 compare to 90 on admission, respiratory was 20, blood pressure was 118/48 and his admitted blood pressure was 140/63 which fell to 98/56 on the night of his admission when he was sleeping.
General: on my shift he was alert and oriented X3 and alopecic along with a mild sclera icterus (yellow eyeball). He was obese with striate on his skin. He had 4+ mid epigastria tenderness. Heart: he was tachycardiac at rest. HEENT (Head Ears Eyes Nose Throat): he had his visual impairment as described. Genitalia: he was a tanner v-male (hair extends to medial surface of the thighs), with bilaterally descended tests. He has a double lumen broriac which is function well.
Airway and breathing: he was on room air with the respiratory of 20 and 97% saturation, and his longs were clear to auscultation. Circulation: he had +2 pulses equal on his both hands and feet with +2 seconds of capillary refill. GI: his abdomen were soft and round, equal and non tender. Bowel sounds were present on all four quadrants. P. M received IV fluids, IV antiemetic to treat his vomiting, nausea, and stomach ache. He also received red cells and platelet transfusions to repair his pancytopenia. He had a re consultation with Dr.
Jane Kelly concerning his retinal hemorrhages, and on doctor exams they appeared to be improved. During the course of this hospital stay, P. M developed strep sanguine sepsis with a positive culture on my shift on 10/14/08, for this he received cefepime and vaccomycin. By the day of his discharge after he got readmitted, he was eating a regular diet and had participated in the Halloween parade. He had no further fevers and was more than ready to go home. Also his lab results before discharge were as follow: