Physical Assessment

General appearance
Weak Looking, arrousable, in Respiratory distress

Vital Signs
BP- 90/60mmhg
HR: 109bpm
RR: 32cpm
Temp: 36.4C

O2sat: 80 at room air, 91% at 4lpm

Head:
No massess or lessions
Eyes:
Anicteric sclera, no periorbital swelling, pale palpebral conjunctiva,
Ears:
Pinna is curved with firm recoil, symmetrical, no discharges, no otalgia, no
discharges, masses or lessions
Nose:
Septum midline, Patent nasal passage, no discharges/bleeding , no nasal flaring
Mouth and throat:
Lips are dry and pale , buccal mucosa are pale.
Neck:
Trachea midline, no lumps no massess
Neck veins not distended

Chest and Lungs

Labored breathing, Equal chest expnsion, Clear breath sounds, no retractions, equal
tactile fremitus

Cardiovascular:
Good cardiac tone, normal rate regular rythym with distinct S1 and S2, no murmurs
noted

Abdomen:
flat soft abdomen, normoactive bowel sounds, no massess,tenderness, non palpable
bladder, liver span 8cm, no organomegaly, no spleenomegaly

Extremities:
Full equal pulses, capillary refill time 2-3 sec, pitting edema at right leg ~4cm calf
swelling, tenderness of the dorsal leg to the thigh but not erythematous, positive
homans sign

GORDONS ????