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Leonard Tyson: Physical Examination

P. E. reveals a thin elderly man who is awake but minimally responsive to questioning or stimuli.

Vital signs

Temp 100.2 degrees; pulse 120 and irregular; R 16; BP 170/82.

HEENT

Conj normal; bilateral cataracts prevent fundoscopy; oropharynx has dry mucosa but no erythema.

Lymph nodes

None palpable.

Chest

Clear.

Heart

JVP 5 cm. Irreg irreg with variable S1 intensity, loud S2, no murmurs or rubs.

Abdomen

Soft; no masses or hepatosplenomegaly.

Extremities

No edema.

G/R

Normal; heme neg.

Skin

Dry with decreased turgor but no rash or lesions.

Neurological exam

Minimally responsive to questions and stimulation; cannot cooperate with cranial nerve, motor, cerebellar exam; reflexes are diminished throughout; Babinski signs are negative.

Next: Test results