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deep breath for me, please? Can you sit, please? Can you turn to your left side, please? I am going to examine your legs to check fluid retention, is that okay with you? I need to check the pulse in your arm and legs now,第八頁,共十七頁。,Patient note,VS: vital signs WNL: within normal limits Chest: nontender, lungs clear to Aamp。P (auscultation and percussion), Auscultation: decreased breath sounds[L/R] Abnormal sounds: wheeze, rub, rale [L/R] [base/midlung/apex],第九頁,共十七頁。,CV: cardiovascular,S1, S2 WNL Regular rate amp。 rhythm, RRR No rub/gallops/murmur sitting and supine (no RGM) No JVD ( jugular venous distention) PMI not displaced (point of maximal impulse ) No clubbing, edema Carotid, radial, DP(dorsi pedis), pulse NL amp。 equal B/L absent/decreased/NL/bounding No carotid bruits,第十頁