.

3️⃣ Explain BACKGROUND history of the patient

⚠️Demographic

Patient name is X
(Age) 40yo man
(Weight) 70kg
(height) 165cm
(bmi) 26

⚠️Comorbids

- DM
(Prev meds) on insulin 20u bd
(Prev Control) HbA1c 8
(Prev Complication) no hx of DKA
(Current control) latest dscan 8, vbg not taken
(Current meds) sliding scale 10

- HPT
(Prev meds) on Amlodipine 10mg od
(Prev control) baseline BP 150/90
(Prev complication) no recent hospitalisation, NYHA 1, CCS 1
(Current control) 130/70
(Current meds) amlo served this morning
.

⚠️ HOPI; History of Presentating Illness

(History) 3 days history of abdominal pain, ass with fever, LOA etc
(Complications) dehydrated, septic looking
.

4️⃣ ASSESSMENT of the patient & ACTION that has been done by the primary team

(Diagnosis) treated as Perforated appendicitis
(Management done) resusitated with fluids, started on cefobid/flagyl

Currently, patient is;
(Vitals)
(GCS) alert
(BP) 130/60 unsupported
(HR) 70-80
(Spo2) 100% under RA
(temperature) afebrile for 24 hours since started antibiotics

(Ix)
(Fbc) twc/hb/plt
(Rp) urea/creat
(Coag) INT
(Cxr) clear, no cardiomegaly; cardiothoracic index ?
(Ecg) sinus, no LVH

(Others)
(RTK) -ve
(GSH/GXM) reported
(LM) 4pm
(Consent) ready

5️⃣ REQUEST

(Ok?) Can i send the booking form/patient?