Day 1 · 08:30 · Ward review
Vaguely unwell
Admitted for diuretic adjustment. Overnight he became quieter than usual; the nurse reports he refused breakfast and 'seems muddled'. He says his belly aches, 'maybe a six out of ten', and he feels cold.
Vitals
HR104BP96/58RR20SpO296%T37.9
History
- Change in the ascites?
- 'Same as always', he says; the belt notches disagree by one.
- Bowels, urine?
- Constipated two days; urine darker and less of it.
- Alcohol?
- None for eight months, attested by family.
Examination
- Abdomen: Tense ascites, diffusely tender without rigidity; no rebound
- Neurological: Oriented to person and place, not date; no asterixis yet
- General: Jaundiced sclerae, cool peripheries
Build the problem list
One problem per line, most urgent first. Abbreviations are fine.