• BP : 130/90 mmHg
• HR : 120x/minute
• RR : 30x/minute
• T : 37,5 C
• Skin: skin turgor is normal
• Eye
• Conjunctiva are anemic +/+
• Sclera are icteric -/-
• Lung:
• Inspection: simetric at statis and dinamic
• Palpation: left = right fremitus
• Percussion: sonor
• Auscultation: Bronchovesicular, rales +/+, wheezing -/-
• Cor:
• Inspection: ictus not seen
• Palpation: ictus is palpated at 1 finger medial LMCS RIC V
• Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: RIC II
• Auscultation: pure rhythm, murmur (-)
• Abdomen:
• Inspection: enlargement (-)
• Palpation: hepar and lien is not palpable
• Percussion: tympani
• Auscultation: bowel sound (+) normal
• Extremities:
• Physiologic Reflex +/+
• Pathologic Reflex -/-
• Oedema -/-
Laboratory