Physical examination

Patient is conscious, coheren but unable to hear questions. SHe seems weakened and
tired, and sits in a slightly slumped position. . He looks distressed and drowsy, slightly irritable, but
not in a severe state of discomfort.

Vital Signs:

Temperature: 37.8

HR: 84

RR: 24 cpm

BP: 130/80 mmHg

Skin: palms and skin are cold but pink in color. Solar lentigo scattered in the upper extremities.
Nails without clubbing and cyanosis

HEENT:

Head: Hair is gray and has an average texture and normal distribution. Scalp without lesion,
normocephalic and atraumatic

Eyes: opaque lens noted on both eyes. Pupils do not responds to light extraocular movement
however is intact.

Ears: Patient has decreased hearing right side. Has no tinnitus and discharge

Nose: Patient has a pale nasal mucosa, with the septum in midline, no sinus tenderness, flaring,
or obstruction; intact olfactory sense on bilateral nostrils.

Mouth: Patient has pale oral mucosa; tongue and uvula are in the midline.

Throat: No hoarseness of voice.

Neck: Trachea in the midline; thyroid isthmus is barely palpable, and the lobes are not felt.

Lymph Nodes: Patient has bilateral small (<1 cm), soft, non-tender, and mobile tonsillar and
posterior cervical nodes.

Thorax and Lungs:

Anterior Chest: Anterior thorax is symmetric. No deformities upon palpation. Ribs and
intercostal spaces are not prominent. Patient uses accessory muscles in respiration. Lung
expansion is symmetrical; no prominent retractions. Lungs are resonant. No increased or
 decreased fremitus. No egophony and whispered pectoriloquy noted, negative for
bronchophony. Breath sounds vesicular without any adventitious breath sounds.

Posterior Chest: Posterior thorax is symmetric with good expansion, without any deformities.
Patient does not have any abnormal retractions. No tender areas and visible abnormalities
upon palpation. No increased or decreased fremitus. Lungs are resonant. Breath sounds
are bronchovesicular on second and third interspace, vesicular on most part of both lungs
and without any adventitious breath sounds.

Cardiovascular: The patient’s jugular veins unremarkable. Upon palpation, no heaves, lifts or thrills
were noted. His point of maximal impulse can be seen and palpated at the 5th intercostal space,
midclavicular line, and left sternal border. He has no carotid bruits, murmurs, or S3 and S4 sounds.
No other remarkable findings upon auscultation.

Peripheral Vascular: Extrimities are pale. Have rhythmic peripheral pulses and a capillary refill less
than 2 seconds. He has no signs of cyanosis or clubbing. Peripheral pulses recorded as follow.

Location Right Left

Carotid +2 +2

Brachial +2 +2

Radial +2 +2

Femoral +2 +2

Popliteal +1 +1

Posterior tibial +1 +1

Dorsalis pedis +1 +1

Musculoskeletal: The patient has good muscle tone. Movements are well-coordinated, accurate,
and smooth; able to move upper and lower extremities, able to move head, neck, and torso. No
evidence of swelling or deformity.

Neurologic: The patient is alert and awake, and can understand questions. She spoke clearly, and
shows no problems with speech and communication. Her thought processes are coherent. No
notable neurologic findings were noted.

Psychiatric: Unusually silent; does not maintain eye contact and frequently fixes eyes in a distant
for a long period of time; only answers question directly.