Vital Signs: Temperature 98°F, Blood Pressure 160/95 mmHg, Heart Rate 85 beats/min, Respiratory Rate 14 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: Breath sounds normal bilaterally, no rales/rhonchi/wheezes
Abdominal: healed abdominal scar, no tenderness, soft, non-distended
Extremities: warm and well perfused, no peripheral edema of extremities
Neurologic: Alert, oriented x3, no focal deficits
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash
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Case 12 Index
Case 12 Introduction