Case 22: Physical Exam

Case 22 Index

Vital Signs: Temperature 100 °F, Blood Pressure 126/98 mmHg, Heart Rate 144 beats/min, Respiratory Rate 14 breaths/min
General Appearance: thin, lying in bed, groaning
HEENT: clear oropharynx, sclera anicteric, mucous membranes dry
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallopsstethoscope
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: does not answer questions or track, moving all extremities spontaneously
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash

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