Physical Examination Findings

General Survey: Patient was seen lying in bed conscious Sensorium was intact. She
was fairly cooperative during the time of examination and was not in acute distress.

Vital Signs: Blood Pressure: 160/70 Right Foot Heart Rate: 63/min Respiratory Rate:
20/min
Temperature: 36.8 O2 Saturation: 92

Skin: Skin is pale and dry, skin turgor is poor, fingernails are large with capillary refill of
< 2 seconds. Hair is short, dry, black, equally distributed. No rashes noted, or lesions,
and nails are not clubbing.

Eyes: Sclera is white, pale palpebral conjunctiva noted, pupils are equally round and
reactive to light. He has normal EOM; able to follow six cardinal points of gaze. No
nystagmus, exophthalmos, and ptosis observed.

Ears: Pinna of ears is in line with outer canthus of eyes. Ears are symmetrical and
elastic with intact bilateral tympanic membranes. Normal hearing and no lesions and
discharges.

Nose: Nose is in centrally aligned. Has midline nasal septum. Bilateral patent nares
were observed with moist nasal mucosa and hair. No discharges.

Mouth: Mouth is dry and lips are pale. Oral mucosa is pink and moist. Tongue is pink
and is able to move voluntarily. Centrally aligned and negative bleeding gums noted.

Neck: Trachea is centrally located and movable; with intact range of motion and no
stiffness and palpable masses nor lymphadenopathy noted. No vein distention. Equal
carotid pulses.

Other Lymph Nodes: Unremarkable

Heart: Adynamic precordium. PMI is noted at 5th intercostal space left anterior axillary
line and with regular heart rate and rhythm. Jugular venous pressure was not
measured. Crisp S1 and S2. At the base, S2 louder than S1. At apex, S1 is louder than
S2. Murmurs and extra sound were not appreciated.

Chest and Lungs: No scars. No visible masses. No intercostal retractions. Regular

unlabored respirations – no apnea. Clear breath sounds. Symmetrical chest
expansions. Chest is resonant. No palpable masses.

Abdomen: Abdomen is flat. No surgical scars. No hernia. Bowel sounds: 15

(normoactive). No tenderness. Bladder is not distended. No palpable masses.
 Musculoskeletal/Extremities
Extremities are warm with mild edema. No peripheral cyanosis noted. Calves are non-
tender. Radial pulses were 3+ and symmetric. Posterior tibial pulses were 3+ and
symmetric. Negative bounding radial pulse. Femoral catheter access was noted for
dialysis.

Neurological. Oriented to person, place, and time. Cranial nerves II–XII intact. Motor: Tone intact.
Strength 4/5 throughout. RAMs, finger-to-nose intact. Sensation intact to pinprick, light touch, position,
and vibration.