View all of the results of the patient examination (click on each system below to view the results).
General Examination
Observations:
- Temperature 36.8°C
- BP 112/72
- HR 86 beats/min
- SaO2 96% on 2 litres of oxygen via nasal specs
- RR 18/min
- Blood sugar 5.2 on sliding scale
- Awake and alert, sitting up in bed, able to talk in full sentences but in some pain
- Using a PCA (patient controlled analgesia) pump for pain relief
- Appears to be a little dehydrated with dry mucous membranes but mouth breathing.
- Weight 95Kg (BMI 31.7)
Cardiovascular System
- Fresh sternotomy scar
- JVP visible at +1cm when at 45 degrees
- Heart sounds normal, no peripheral oedema
Respiratory System
- Trachea central
- Chest – equal expansion, resonant, normal tactile vocal fremitus
- Vesicular breath sounds bilaterally but reduced air entry at both bases
Gastrointestinal System
- Abdomen: Soft and non-tender. Normal bowel sounds.
Nervous System
- Neurological system not examined but no obvious abnormalities.
Musculoskeletal System
- Exam not performed
Genitourinary System
- Exam not performed
Urinalysis
- see later....
Mental/Psychiatric Exam
- Exam not performed
Other
- None