Some creepitant rales noted in the anterior and posterior chest. There is slight increase in the heart rate otherwise rhythm is regular. No murmur, rub or gallop. A panninculus overlies the lower abdomen that rests on the upper thighs when the patient is sitting. Too many milk and cookies.
Bowel sounds are normoactive.
Although it is difficult to palpate, there appears to be no hepanosplenmegaly. Exam deferr per patient request. Exam defer at this time. The extremities show no cyanosis or edema. There are multiple scratche and scars noted on the lower limbs and on the hands.