Case 2: Physical Exam

Vital Signs: Temperature 98.9°F, Blood Pressure 138/88 mmHg, Heart Rate 80 beats/min, Respiratory Rate 12 breaths/min

General Appearance: In no acute distress
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx
LAD: No lymphadenopathy
stethoscopeCardiovascular: No JVD, Regular rate and rhythm, no murmur, rub, or gallop
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly
Extremities: Warm and well-perfused, 1+ bilateral pitting edema to bilateral ankles
Neurologic: Alert, Oriented x3, no focal deficits
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rashes

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