Vital Signs: Temperature 98.8°F, Blood Pressure 160/90 mmHg, Heart Rate 84 beats/min, Respiratory Rate 14 breaths/min
General Appearance: In no acute distress, thin
HEENT: conjunctival pallor, no scleral icterus, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Pulmonary: Breath sounds normal bilaterally, no rales/rhonchi/wheezes
Abdominal: soft, non-tender, non-distended, healed right lower quadrant abdominal scar with no tenderness with graft palpation
Extremities: warm and well perfused, +1 peripheral edema of extremities
Back: moderate tenderness to palpation of lower back over vertebrae, no rash
Neurologic: Alert, awake, answers appropriately
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash
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Case 21 Index
Case 21 Introduction