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Miriam Strichen: Physical Examination

P.E. reveals a thin woman with protuberant abdomen in mild respiratory distress.

Vital signs

Temp 99 degrees; pulse 100; R 30; BP 120/80.

HEENT

Conj nl; fundi - normal; oropharynx - dry without lesions.

Lymph nodes

None palbable.

Chest

Clear with decreased breath sounds at both bases about 1/4 way up; percussion note is dull over the same area and there is an absence of tactile fremitus at both bases. COR - JVP is 6 cm; RRR with no murmurs, gallops or rubs audible.

Heart

PMI palpable in the 5th ICS, MCL; S1 and S2 irregularly irregular with variable intensity of S1, no gallops or murmurs.

Abdomen

Protuberant but symmetrical on inspection; there are no palpable masses; liver and spleen are not palpable; there is mild tenderness throughout but no rebound pain; shifting dullness and fluid wave are demonstrable; BS are diminished but present.

G/R

Speculum exam is normal; rectum is normal; stool heme negative.

Extremities

2+ edema.

Skin

Normal, without lesions or angiomata.

Neurological exam

None-focal.

Next: Test results