l Vital signs：BP:162/
108 mmHg, BT:37 °C, PR:100 /min, RR:18 /min, SpO2:100 %, Pain score: 0/10
l General：chronic
ill-looking | (Description of findings)
l Consciousness：
-
alert
and clear (to person, time and place. GCS: E4M6V5
l HEENT (head, eyes, ears,
nose, and throat)：
-
no
head deformity,
-
pink
conjunctivae, anicteric sclera
-
isocoric
pupil (R/L): 3mm/3mm, prompt light reflex (R/L): positive/positive
-
ear:
normal appearance
-
throat:
no injection, no ulcers, no pus
l NECK：
-
supple,
no Brudzinski's sign, no Kernig's sign,
-
no
carotid bruit
-
normal
estimate CVP (< 3+5cm), no jugular vein engorgement, no absent A wave (AF),
no giant A wave (TS, PHT), no cannon A wave (AV dissociation), no large V wave
(TR), no slowly Y wave (TS), no hepato-jugular reflux (HF), no Kussmal's sign (Constrictive
pericarditis, HF)
-
no
palpable lymph nodes, no palpable thyroid gland
-
no
difficult airway (3-3-2)
l CHEST：
-
Inspection:
symmetric expansion, no visible chest deformity, no scar, no use of accessory
respiratory muscle, no spider angiomata
-
Palpation:
no increased tactil fremitus
-
Percussion:
bilateral resonant, no hyperresonance, no dullness, normal cardiac silhouette
on percussion
-
Auscultation:
bilateral symmetric clear breath sound, no crackles, no wheezing, no rhonchi,
no rales, no bronchophony, no egophony
l HEART：
-
Inspection:
no visible PMI, parasternal lift, dyskinesis and aneurysm
-
Palpation:
PMI over left 4th intercostal space and medial to the mid-clavicular line, no
RV heave (volume load / pressure load), no left 2nd interspace lift (pulmonary:
PHT), no right 2nd interspace lift (aortic: HTN), no epigastric area lift (RV
in hyperinflated lungs), no thrills (Gr. 4+ murmurs) over 4 vulvular area, no
ectopic heave or thrill
-
Percussion:
normal cardiac silhouette on percussion
-
Auscultation:
regular heart beat, normal S1 and S2, no S1 decreasement, no pathological S2 splitting,
no S3, no S4, no gallop, no audible murmur no extra systolic/diastolic sounds
(Ejection sound (AS), Mid-systolic click (MVP), Opening snap (MS, TS)), no
audible murmurs / abnormal heart sounds on squatting, valsalva / standing,
inspiration maneuvers
l ABDOMEN：
-
Inspection:
flat, no scar, no umbilical hernia, no engorged superficial vein, no caput
medusae, no Cullen's sign, no Grey-Turner's sign
-
Auscultation:
normoactive bowel sound, no bruits
-
Palpation:
soft, no tenderness, no muscle guarding, no rebound tenderness, no Murphy`s
sign, no McBurney's point tenderness, no Psoas' sign, no Obturator's sign,
impalpable liver and spleen, no palpable mass
-
Percussion:
no tympany, no shifting dullness, no percussion wave, no succussion splash,
-
liver
span: normal span at right mid-clavicular line
l BACK：
-
no
CV angles knocking tenderness
-
no
kyphosis, no scoliosis
-
negative
straight leg raising test
l EXTREMITIES：
-
freely
movable, no deformity, no peripheral cyanosis, no clubbing finger, no palmar
erythema, no pitting edema
-
radial
pulsation: normal pulse rate, regular rhythm, no pulsus alternans(HF), no
pulsus parvus et tardus (AS), no pulsus paradoxus (Pericardial tamponade,
Constric pericarditis), no pulsus bisferiens (HOCUM), nobounding pulse (Chronic
AR), no bigeninal (Premature beats), no dicrotic (Cardiomegaly), no filiform
(Shock)
l LYMPH NODES：
-
no
neck, no axillary, no epitrochlear, no inguinal, no popliteal LAP
l DIGITAL RECTAL EXAMINATION：
-
no
skin tag, no visible hemorroid, no anal fissure, no perianal abscess, no anal
fistula, tight anal tone, smooth rectal wall, no induration, no rectal shelf,
no tenderness
-
brownish
color stool over glove
-
prostate
(indicated in male patient): egg-sized, no enlargement, elastic character,
normal sulcus, no palpable mass, no tenderness
l Integument: normal skin
turgor, no cyanosis, no skin rash
