Examinations
View all of the results of the patient examination (click on each system below to view the results).
General Examination
- Caucasian woman of approximately 60 Kg in weight.Confused and agitated but awake and alert. Not attempting to get off the trolley. Smells of urine and clothes are damp. She appears dehydrated with dry mucous membranes.
- Temperature 38.4 oC. Oxygen saturations 97% on room air. Blood glucose on finger prick 5 mmol/L
Cardiovascular System
- Pulse 100 bpm, blood pressure 95/60, JVP not seen (low)
- Heart sounds normal
- No peripheral oedema
Respiratory System
- Respiratory rate 22 breaths per minute
- Trachea central
- Apex beat not displaced
- Expansion: equal both sides
- Percussion: resonant on both sides
- Tactile vocal fremitus: normal
- Breath sounds: normal
Gastrointestinal System
- Abdomen soft, no organomegaly, no masses palpable. Tender in the supra-pubic region
Nervous System
- No obvious abnormalities, moving all 4 limbs equally with no evidence of pain but not responding to commands appropriately. No obvious cranial nerve abnormalities. Pupils equally reactive to light.
Musculoskeletal System
- No obvious abnormalities, moving all 4 limbs equally with no evidence of pain but not responding to commands appropriately.
Reticuloendothelial System
- No palpable lymphadenopathy
Genitourinary System
- External genitalia not examined
Urinalysis
- Blood ++, protein trace, leucocytes ++, nitrites ++, glucose negative, ketones negative, pH 5
Mental/Psychiatric Exam
- Glasgow Coma Scale 11 (E4V3M4)
- 4AT score for delirium 8
Other
- Urine microscopy: Red blood cells, white bloods cells and rod shaped bacterial organisms seen. Urine sent for culture