SUBJECTIVE:

Patient’s complain of abdominal tenderness, nausea, and

vomiting. 2 days ago, patient experienced nausea, vomiting,
diarrhoea and chills.

OBJECTIVE:

Physical examinations: ill-appearing woman who is lethargic but

responsive
Temperature: 37˚C
Skin turgor: poor
Mucous membrane: dry
Eyeballs: shrunken and soft
Lungs: clear but respirations are deep and her breath has a fruity odor
Cardiac examination: within normal limits

Vital signs: Result Normal range Implication

Supine position:
Pulse rate 115 beats/min. 60-100 High
beats/min
Blood pressure 105/60 mmHg 120/80 mmHg Low
Upright position:
Pulse rate 140 beats/min 60-100 High
beats/min
Blood pressure 85/40 mmHg 120/80 mmHg Low

Electrolytes and Result Normal range Implication

Blood chemistry:
Blood glucose 750mg/dL 70-110mg/dL High
Sodium 148 mEq/L 135- 147 mEq/L High

Potassium 5.4 mEq/L 3.5-5.0 mEq/L High

Chlorine 106mEq/L 95-105 mEq/L High

Bicarbonate 6mEq/L 22-28 mEq/L Low
 SrCr 2.0 mg/dL 0.6-1.2 mg/dL High
Complete blood Result Normal range Implication
count:
Hemoglobin 14.7g/dL 11.5-15.5g/Dl Normal
Hematocrit 49% 33%-43% High
WBC 15,000mm^3 3,200- High
9,800mm^3
Bands 3% 3-5% Normal
Polymorphonuclear 70% 54-62% High
neutrophils
Lymphocytes 27% 25-33% Normal
Serum ketones negative Normal
Urinalysis: Result Normal range Implication
Glucose 2% 0 High
pH 5.5 2.6-8 Normal
Specific gravity 1.029 1.020-1.025 High
Arterial blood gas: Result Normal range Implication
pH 7.05 7.36-7.44 Low
Pco2 20 mmHg 35-45 mmHg Low
Po2 120 mmHg 90-100 mmHg High