NOSE AND Inspection:

SINUSES
Patient R.’s nose appeared symmetric, straight and there is a
yellowish tinge in color. There is a presence of mucus discharge. No
flaring, tenderness and lesions observed.

THORAX AND Inspection:

LUNGS  Patient R has difficulty breathing in a supine position, there is
irregular, shallow, breathing through mouth and uses accessory
muscle for breathing and has audible breath sounds.

Auscultation:

Bilateral coarse crackles and wheezing sounds on lower lobes heard

upon auscultation with decreased breath sounds at posterior area.  

BREASTS Inspection:

The breasts are symmetrical, non-tender and have no suspicious

masses and no secretions.

HEART Inspection:

The JVP (Jugular Venous Pressure) is 3cm above sternal angle and
the apex beat is palpated in the 5th intercostal space, midclavicular
line, no palpable thrills over valve areas and precordial heaves.

The external chest is normal in appearance without lifts, heaves, or

thrills.

Palpitation:

PMI (Point of Maximal Impulse) is not visible and is palpated in the

5th intercostal space at the midclavicular line.

The radial pulse is above normal and symmetrical. Carotid pulse is

above normal, and the pulse rate is 110bpm.

Auscultation:

There is no S3/S4 (S3 is the 3rd heart sound also known as

“ventricular gallop. It is a low-pitched sound that doctors can hear
when blood rushes rapidly from the heart's atrium into the ventricle.)

(S4 is the 4th heart sound, it is a low-pitched sound coincident with

late diastolic filling of the ventricle due to atrial contraction.) detected,
no murmurs, gallops, or rubs are auscultated.

The patient heart rate is 110 bpm and the BP is 150/100 mmHg.