Case 23: Physical Exam

Case 23 Index

Vital Signs: Temperature 98.5 °F, Blood Pressure 99/67 mmHg, Heart Rate 65 beats/min, Respiratory Rate 14 breaths/min
General Appearance: well appearing
HEENT: clear oropharynx, sclera anicteric, mucous membranes moist
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
Extremities: warm and well perfused, no pitting lower extremity edema
Back: fullness of both flanks, no costovertebral angle (CVA) tenderness, no spinal tenderness 
Neurologic: awake, alert, and answers appropriately
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash

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