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YSM ONLINE CASEBOOK YALE UNIVERSITY SCHOOL OF MEDICINE
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Physical Examination

P. E. reveals an intubated alert man in no acute distress.

Vital signs

Temp 97.3 degrees; pulse 96; R 12; BP 110/86.

HEENT

Conjunctivae are benign; fundi reveal grade 2 hypertensive changes; oropharynx is intubated and poorly visualized.

Lymph nodes

None palpable.

Chest

Clear on the ventilator; sternotomy incision looks normal.

Heart

RRR with distant heart sounds; no murmurs or rubs.

Abdomen

Soft nontender, without organomegaly; no flank tenderness; bowel sounds are diminished.

G/R

Foley catheter in place; rectal normal; heme negative.

Extremities

Saphenous vein harvest site benign; no edema.

Skin

No rash or lesions noted; normal turgor.

Neurological exam

Nonfocal.


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