Vital Signs: Temperature 99°F, Blood Pressure 170/100 mmHg, Heart Rate 95 beats/min, Respiratory Rate 18 breaths/min
General Appearance: In no acute distress
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Pulmonary: Bibasilar rales, no wheezes or rhonchi, mildly labored breathing (click here for bedside lung ultrasound)
Abdominal: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly
Extremities: warm and well perfused extremities, minimal erythema on R shin, 1+ bilateral pitting edema to shins bilaterally
Neurologic: Alert, Oriented x3, no focal deficits
Psychiatric: Calm, pleasant
Skin: Warm, dry
Click here to move on!
Case 1 Index
Case 1 Introduction