PHYSICAL EXAMINATION GENERAL: - AA&O (alert, awake, orientated), pleasant and appropriate, comfortable, cheerfull, distracted, drowsy, confused

and unfocused, jittery (unruhig), grumpy, irritable, edgy (nervous), sleepy but easily arousable - no apparent distress, in acute distress, diaphoretic (schwitzend) - well nourished/developed, emaciated, older/younger than stated VITAL SIGNS : - BP: P: Resp: (un/labored) Temp:

Wheight:

(gain/losses)

HEENT (head, ear, eye, nose, throat): - Othoscope: Fundi unremarkabel, difficult to exam, tympanic membrane/ear canal clear, pearly, wax - PEERLA: pupil equal, round, reactive to light and accomadation; opacified, irregular - EOMI: extraocular eye movement intact, no double visions, visual acuity unchanged, difficulty tracking finger, visual fields grossly intact - sclerae clean/conjunctivae pale, yellow/jaundice/anicteric - oropharynx well hydrated/exsudates/plaques, mucous membranes moist, no sore throat, no ulcerations, tongue plaques/wrinkeld/moist/white and coated/fasciculating, midline, no cyanosis - sens. V inatct, no facial droop, swallowing intact, CNs II-XII grossly intact NECK: - no lymphadenopathy, no lymph nodes palpabel, tender, hard, soft, mobile/immobile - thyroid gland normal/unremarkebal, goiter, neck is supple, no stiffness, FROM (full range of motions), no carotid bruits SKIN: - normal tugor, decreased, rashes, lesions, decubiti, sool, dry, moist, pink, brown, gray, ashes, cyanotic, - stasis dermatosis LE (lower extrem.), oozing or draining incisions/wounds, positive seborrheic keratosis, no acute dermatitis noted, no bruises LUNGS: - clear to A&P, CAT (clear to auscult.), crackles/ rales, rhonchi (phlegm derived), wheezing (giemen), stridor, shallow/moderate/deep/regular/labored, in/decreased BS (breath sounds), one third up bilateral, clear to bases, clear after cough, no dullnesss to percussion - no coughing, yellowish/ whitish /bloody sputum or phlegm HEART: - normal S1S2, diminished, no m (murmurs), no gallops, no rubs, x/VI m over .., fixed splitting, no additional HS (S3S4), RRR (regular rate and rhythm) - SOB (shortness of breath) on exertion, PND (paroxysmal nocturnal dyspnea), orthopnoe - no carotides bruits, pulses 2+ bs (both sides), JVD (jugular venous distention), filled up x cm above clavicle, no JVD - edema ankles, pretibial pitting edema up to calves/midshin/knees, nycturia

ABDOMEN: - soft and nontender, abdominal wall distended, flat, guarding, rebound pain, referred tenderness to RLQ, pain on moderate, deep, slight palpation/percussion - no masses, no lumps, hepatic/spleen enlargement 3 fgr. below RCM (right costal margin), no organomegaly, no ascites - BS (bowl sounds) +, diminished, hyperactive, normoactive, no aortic bruits - no CVAT (costovertebral angle non tender = kidney), water passing pain related, burning sensations, dark urine

diarrhoea, obstipation, stool: formed, loose, watery, brown, tarry (teerig), black, red, BRBPR (bright red blood per rectum), pain related to meal/bowl movement/water passing femoral pulses 2+ bs, no herniae

RECTAL: - hemorrhoid, masses, stool heme+, prostate small soft, not being performed, refused EXTREMITIES: - no c/c/e (cyanosis, clubbing (Trommelschlegel), edema), pitting edema up to knee/mid shin/calves - pulses 2+ fem(groin), pop, ped, tib post (foot) - walking related pain - strenght equal bs 4+/5, 5/5 for UE and LE, proximally/distally strenghts, no rigidity, motor exam showed normal tonus throughout, FROM (full range of motions), no clumsiness, no pain on straight leg raising at about xy degree, moved all four extremities NEURO: - A&Ox3 (alert and orientated to time/place/self) - mental: alert, awake, lethargic, unresponsive, droozy, distracted, delayed responsive, - affect: anxious, sad, flat, euphoric, labile, calm, angry, jittery, suicidal - vocal quality changes, blurred visions (schleiersehen), headaches, dizziness DTRs (deep tendon reflexes) 2+/4 UE and LE, hyper/hypo/normoreactive, similar to both sides, throughout, grossly intact, vibration intact, reduced in stockwise contribution, distinction sharp/dull diminished, proprioception grossly intact - higher coordination intact, finger-finger-test, finger-nose-test, dysmetria, diadochokinese UE, rapid alternating, movements normal, finger-thumb, finger I to II-V, strechted arm, supinated eyes closed, troemmler, heel-shin-test, trendelenburg 1.-3.(1.feet spread apart, 2.feet close together, 3. eyes closed), gait: unsteady, unsafe, shuffling, small steps, dragging, normal cerebellar functions
GRADING TABLES:
REFLEXES
0 +1 2+ 3+ 4+ absent hypoactive normal brisker than average brisk, hyperactive, clonus absent muscular contractions

Muscle Strengh :
1

minimal contraction 2 3 4 5 active movement with gravity eliminated active movement against gravity only active movement gainst gravity and some resistance normal diminished expected full/increased pounding varies from beat to beat, LV failure

pulses:

1+ 2+ 3+ 4+ pulsus alternans:

pulsus paradoxus: amplitude decreases during inspir.

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