Cardiovascular Hx Reporting

On examination, the patient looks comfortable at rest and is warm and well perfused.
There were no peripheral signs of infective endocarditis congestive heart failure. No
signs of anaemia or cyanosis. HR, BP. JVP wasnt elevated, no bruits auscultated.
On examination of the praecordium there was no evidence of thrills or heaves and the
apex beat was not displaced. On auscultation heart sounds were dual with no murmurs
or added sounds. Lung bases were clear. No hepatomegaly, splenomegaly or
peripheral oedema evident. Peripheral pulses present with good capillary return.
Respiratory Hx Reporting
On examination of the patients respiratory system, the patient looks comfortable at
rest and there is no use of the accessory muscles with respiration or cyanosis. There
were no peripheral signs of chronic lung disease or hypercapnia. The pts pulse was
. and respiratory rate was . There was no evidence of Horners Syndrome or
central cyanosis. Trachea is midline. On examination of the chest there were no signs
of skeletal abnormalities, chest expansion was symmetrical, percussion was resonant
and equal on both sides. On auscultation of the anterior and posterior chest there was
good bilateral air entry which were vesicular in nature and no adventitious sounds
(crepitations or wheeze).
Haematological System
On examination there was no evidence of anaemia, petechial bruising, jaundice or
joint arthroses. There was no lymphadenopathy in cervical, axillary, or inguinal
lymph nodes. There were no signs of stomatitis, glossitis or gum hypertrophy. No
hepatosplenomegaly.