Triage note
The client lives in a college dormitory. Temperature is 39.5 C with marked neck stiffness. The client reports severe headache and vomiting. Skin assessment shows a rapidly spreading nonblanching petechial rash. Blood pressure is 86/48 mm Hg. Heart rate is 128/min. Capillary refill is 4 seconds. The client is disoriented to place and time. Oxygen saturation is 93% on room air. Symptoms began 12 hours ago.
檢傷紀錄
個案住在大學宿舍。體溫為39.5°C 且有明顯頸部僵硬。個案主訴嚴重頭痛和嘔吐。皮膚評估顯示快速擴散的不會泛白瘀點皮疹。血壓為86/48 mm Hg。心率為128 次/分。微血管回充時間為4 秒。個案對地點和時間失去定向感。血氧飽和度為室內空氣下 93%。症狀開始於12 小時前。