PHYSICAL EXAMINATION

Vital signs
Temperature: 36.7
PR: 86 bpm
RR: 18 /min
*Unable to get blood pressure due to insufficiency of cuff to accommodate patient and no
pediatric cuff available on site.*

General Survey
The patient is alert, well-groomed, but appears sad and fatigued. LR is noticeably frail and in
discomfort, lying down and refusing to be seated upright. The patient is oriented to person,
place, and time; her alertness and interest in environment is decreased. LR was awake and
responded slowly; her speech is slow and words are mumbled. Patient was attentive to most
questions, made eye contact, but at times appeared dull and irritable.

Skin and Hair

Skin is warm and dry with fair turgor, no cyanosis or jaundice. Bipedal pitting ankle edema
noted. Nails with with no clubbing, oil spots or loosening. Patient has a 5 x 2.5 cm ecchymoses
located at left antecubital area. Hair is coarse and dry with diffuse thin patches. No suspicious
nevi, rash or petechiae noted.

Chest & Lungs

Thorax symmetric with good expansion. No signs of distress. Tactile fremitus present and equal
on both sides. Lungs resonant on percussion. Breath sounds symmetric and vesicular; no rales,
wheezes, rhonchi, stridor, pleural friction rub, or mediastinal crunch

Abdomen
Abdomen is flat and symmetrical, with a visible 17 cm vertical scar that runs at the midline 4 cm
above and 13 cm below the sunken umbilicus; It is soft , nontender, tympanic on all four
quadrants, and active bowel sounds of 10/min is heard; no palpable masses or hepatomegaly.
Liver is firm, hard and nontender, span is 8 cm in the right midclavicular line and 4 cm in the
midsternal line; Edge is smooth and palpable 1 cm below the costal margin. Spleen and kidneys
are not palpable. No costovertebral angle tenderness. No aortic pulsations

Musculoskeletal PE
Pitting edema was present on Bilateral ankles. Good range of motion in hands, wrists, elbows,
shoulders, hips, knees and ankles. Muscle strength of major muscle groups was 3/5. Normal
muscle tone. There was no noted asymmetry, head and neck is in midline. No erythema and
tenderness present. No joint deformities. No contractures present. No palpable crepitation was
present on bilateral knees.

Cardiovascular
Adynamic precordium with regular rate and rhythm. S1 and S2 normal. No murmurs, rubs, and
gallops. No JVD or bruits. *PMI was not established. (Could not be felt by 3rd years)* Pulses full
and equal. Pitting edema was noted on bilateral ankles. Capillary refill time is normal. No finger
nail clubbing noted.