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กรณีศึกษาที่ 1 - Coggle Diagram

- - - - Airway : ผู้ป่วยสามารถสื่อสารได้ปกติ พูดได้เต็มประโยค ทางเดินหายใจโล่ง
      - Breathing
        
        O2 sat 92%
        RR = 24/min
      - Circulation
        
        T = 36.8 0 C
        BP = 95/70 mmHg
        Pulse = 132/min (regular)
        Capillary Refill Time = < 2 seconds
        ECG = shows sinus tachycardia
      - Disability
        
        GCS = 15 score
        Pupils equal and reactive to light.
        Normal power in all four limbs.
      - Exposure
        
        No evidence of external bleeding
        No rashes
    - - GA : Thai male, 48 years old, weakness, normal growth and body build, big shape size, black hair, red and black skin, normal consciousness, appropriated orientation.
        
        Skin : pallor,no abnormal pigmentation, normal-looked hair and nails, purpura lesion on left wrist, warm and mild moisture skin.
        
        Head : Normal shape and size, no asymmetry, no tenderness, gray and black hair color, no abnormal face.
        
        Eyes: Normal vision, normal eye movement, no ptosis, no exophthalmos, pale conjunctiva, round and equal pupil, normally respond to light both pupil,. no exophthalmos.
        
        Ear : No abnormal mass or lesion, no hearing loss.
        
        Nose : Symmetrical nose, no septal deviation, no visible blockage, inflammation or erosions in the nostrils.
        
        Mouth & Throat : No oral lesion, pink buccal mucosa and gingival, no enlarged tonsils, no injected pharynx, normal uvula position and movement.
        
        Neck: No lumps or pain, no goiter, no enlarged glands, trachea in midline.
        
        Heart : S- gallop, murmur grade III. HR=123 bpm, regular rhythm.
        
        Lung : a pleural rub is heard over the right lower lobe
        
        Abdomen : Normal size and shape, no distension, active bowel sound, nottender, no mass, liver, spleen can’t be palpated.
        
        Extremities : No deformity, no edema, no cyanosis, normal movement of upper and lower limb.
        
        Lymph node : No lymphadenopathy.
        
        Neurological : Alert, well cooperated, motor power grade V/V all extremities, no sensory impairment, DTR – not examined. Pain score 7/10
        
        Genitalia : Not examined