PRF

Question 1

RS

Answer 1

• NO DIB, SOB ( SOB+, east by GTN)
• chest sounds clear,
• no crackles or wheezes heard,
• no tracheal deviation,
• no flu like symptoms, no obvious covid symptoms
• no pleuritic pain, no cough or cold, bilateral air entry equal rise and fall,
• no nasal flaring,
• no air hunger, no tripoding,
• pt speaking in full sentences

Question 2

CVS

Answer 2

no CCP , no palpitation, no oedema, HR, BP
no radiation pain , no shoulder or back pain, no cardiac history declared.
strong and regular radial pulse
12 leads shows..
(denies any chest pain, )
normotensive,
good skin colour
no peripheral oedema,
no mottled skin

Question 3

CNS

Answer 3

no confusion,
BE FAST-VE
no dizziness, no headache, no blurred vision, no photophobia,
no behaviour changes, NO LOC, apyrexic (no temp), no dysphagia (swallow difficulties) , no nystagmus (involuntary moment of the eyes) , no numbness , no paraesthesia ( burning or prickling sensation) , no aphasia (difficulty with speech),
MSC x4
no head injuries, no cranial nerves intact,
no balance problems , eyes PEARL

Question 4

GIS

Answer 4

no abdominal pain, no distention, no rigidity, no guarding (is a voluntary contraction of the abdominal wall musculature to avoid pain).
no nausea, no vomiting , no haematemesis,
bowels reported as normal,
Normal bowel sounds, appetite reported as normal.

Question 5

GUS

Answer 5

Frequency normal, no retention, no haematuria, no strong smells , no dysuria,
Pt appears well hydrated, positive fluid intake.
Pt reports eating and drinking as normal
reports toileting habbits as normal,
no blood seen when passing.

Question 6

MSK

Answer 6

Reports no injures head to toe, no bruising seen, normal mobility for patient

Question 7

OA

Answer 7

Found patient.. alerted and orientated. Appeared well, Talking in full sentences, good skin colour, well perfused

Question 8

PC
HxPC
Meds
Shx
OE

Tretment given
IMP
Plan

Answer 8

OE: obs as recorded, gcs 15/15, no reported pain

General health - no recent hospital admission, no recent GP service involved, no recent illnesses, no changes to weigh, no fevers or night sweats.
Mental health - pt reports no anxiety or depression, remained calm and relaxed through assessment