Physical Examination

1. Physical Examination On admission Upon PE • Anthropometric Measurements: • Height: 157cm Weight: 74kg BMI: 30 • General Survey • Conscious, coherent, stretcher-borne, in cardiorespiratory distress • Vital Signs • BP: 200/100, supine LUE; 190/100, RUE, SBP 190, LLE, SBP 190 RLE; • PR: 88, regular; • HR:88, regular; • RR:24; • T 36.5 • Conscious coherent, ambulatory, not in cardiorespiratory distress • BP: 110/70; • PR: 76, regular; • HR: 76, regular; • RR: 20, regular; • T 36.0

2. Physical Examination On admission Upon PE • Skin • Warm, moist skin, no flushing, no active dermatoses • HEENT • Pink palpebral conjunctivae, anicteric sclera, (+) ROR, hazy cornea • No nasoaural discharge, septum midline, moist buccal mucosa • No tragal tenderness AU, non-hyperemic external auditory canal AU, intact tympanic membrane AU • Warm, moist skin, no flushing, no active dermatoses • Pink palpebral conjunctivae, anicteric sclerae, (FUNDOS) • no nasal or aural discharge, no nasal deformities, midline septum • Intact tympanic membrane, no tragal tenderness

3. Physical Examination On admission Upon PE • HEENT • Moist buccal mucosa, tongue midline, non-hyperemic PPW, tonsil not enlarged • no limitation in motion, Trachea midline, thyroid gland not enlarged, neck veins not distended, no cervical lymphadenopathy, (-) carotid bruits • Moist buccal mucosa, no oral ulcers • supple neck, thyroid gland not enlarged, no palpable cervical lymphadenopathy, trachea midline, neck veins not distended

4. Physical Examination On admission Upon PE • Cardiovascular • Adynamic precordium, JVP 3cm at 30 degree, AB at 6th LICS 11cm from the midsternal line, tapung, 2cm in diameter, no heaves, no thrills, no lifts S1>S2 apex, S2>S1 base, no murmurs • Pulses full and equal, no edema, no cyanosis, no clubbing • Adynamic precordium, apex beat at 6th LICS 11cm from the midsternal line, no heaves trills lifts, apex S1>S2, base S2>S1, no murmurs, JVP 4cm at 30 degrees • No edema, pulses full and equal on all extremities

5. Cardiac Auscultogram CAP rapid upstroke gradual down stroke JVP 3 cm at 30° A P T M S1 S2 S1 S2 S1 S2 S2 S1 Precordial Activity: Adynamic precordium No heaves, lifts, or thrills Apex beat: 6th LICS 11 cm from midsternal line

6. Physical Examination On admission Upon PE • Pulmonary • Symmetrical chest expansion, no retractions, no lagging, equal tactile and vocal fremiti, resonant on percussion, clear breath sounds • No chest retractions, no use of accessory muscles, normal breathing pattern, symmetrical chest expansion, unimpaired transmission of voice and tactile fremiti, resonant on both sides, vesicular breath sounds on both sides

7. Physical Examination On admission Upon PE • Gastrointestinal • Flabby abdomen, no striaes, no visible peristalsis, NABS, (-) bruits, tympanitic on percussion, no tenderness, liver edge not palpable, Traube’s space not obliterated • Flabby abdomen, normoactive bowel sounds, tympanitic, non-tender, liver dullness 10 cm, Traube’s space not obliterated

8. Physical Examination On admission Upon PE • Neurologic • Awake, alert, conscious, oriented to 3 spheres • CN: no anosmia, pupils 2-3mm ERTL, EOMs intact, V1V2V3 intact and equal, can clench teeth, can smile, can frown, intact hearing, (+) gag reflex, can raise both shoulders against resistance, uvula midline on phonation, can shrug shoulders, tongue midline on protrusion • Conscious, awake, oriented to person, place and time, can follow commands • Cranial nerves intact, (PUPIL) no facial asymmetry, can smile, frown, clench teeth, puff cheeks, normal gross hearing, uvula midline, (+) gag reflex, able to shrug shoulders, turn face against resistance

9. Physical Examination On admission Upon PE • Neurologic • Motor: 5/5 on the lower extremities, 5/5 on the upper extremities, no fasciculations, atrophy • No babinski, bilateral • No sensory deficit • No nuchal rigidity, Kernig’s, Brudzinski’s • Motor 5/5 over all extremities, good tone, no atrophy, no fasciculation • No sensory deficits • (-) Babinski , Kernig, Brudzinski • No nuchal rigidity

10. Salient Features Pertinent Positive • BP on admission: 200/100; RR: 24 (in cardiopulmonary distress) • BMI = 30 • Apex beat at 6th LICS 11cm from the midsternal line • (EYE PE)

11. Salient Features Pertinent Negative • Neck veins not distended • No heaves, no thrills, no lifts S1>S2 apex, S2>S1 base, no murmurs • Pulses full and equal, no edema, no cyanosis, no clubbing • No chest retractions, no use of accessory muscles, symmetrical chest expansion, unimpaired transmission of voice and tactile fremiti, clear breath sounds

12. Chest Pain Cardiovascular Pulmonary Gastrointestinal

13. Blood pressure • The pressure or tension of the blood within the systemic arteries, maintained by the • contraction of the left ventricle • resistance of the arterioles and capillaries • elasticity of the arterial walls • viscosity and volume of blood Stedman’s medical dictionary, 5th Ed

14. Blood Pressure Classification On Admission • LUE 200/110 • RUE 190/100 • LLE 190 systolic • RLE 190 systolic Upon PE • 110/70 Harrison’s Internal Medicine, 17th Ed

15. Clinical Disorders of Hypertension • Essential hypertension/ primary/ idiopathic • Secondary hypertension • a specific mechanism for the blood pressure elevation is apparent • a specific underlying disorder causing the elevation of blood pressure can be identified • Renal, endocrine, adrenal… Harrison’s Internal Medicine, 17th Ed

16. Apex beat • Normal left ventricular apex impulse • left midclavicular line in the 4th or 5th LICS • Left ventricular hypertrophy • exaggeration of the amplitude, duration, and often size of the normal left ventricular thrust • impulse may be displaced laterally and downward into the 6th or 7th ICS (left ventricular volume load; aortic regurgitation or dilated cardiomyopathy) Patient’s Apex beat at 6th LICS 11cm from the midsternal line Harrison’s Internal Medicine, 17th Ed

17. Body Mass Index • weight (kg)/height (m)2 CLASSIFICATION OF WEIGHT STATUS AND RISK OF DISEASE Patient’s BMI = 30 Harrison’s Internal Medicine, 17th Ed

18. **notes from history needed Relevant History • Cardiovascular consequences, comorbidities, lifestyle • Common symptoms: headache, dizziness, palpitations, easy fatigability • Duration of hypertension, previous therapies • Family history – father (+)HTN, mother (+) HTN, siblings (+) HTN, DM • Diet – fond of sweet and salty • weight change Harrison’s Internal Medicine, 17th Ed

19. **notes from history needed • Evidence of secondary hypertension: hx of renal dse, change in appearance, muscle weakness, spells of sweating, palpitations, tremor, erratic sleep, snoring, daytime somnolence, symptoms of hypo/hyperthyroidism, use of agents that may inc bp • Evidence of target organ damage – stroke, transient ischemic attack, angina, transient blindness, MI, CHF Harrison’s Internal Medicine, 17th Ed