Vital Signs: Temperature 99°F, Blood Pressure 110/70 mmHg, Heart Rate 95 beats/min, Respiratory Rate 18 breaths/min
General Appearance: In no acute distress
HEENT: Normal conjunctiva, no scleral icterus, dry mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, Regular rate and rhythm, no murmur, rub, or gallop
Pulmonary: Lungs clear to auscultation bilaterally, no wheezes or rhonchi, normal respiratory effort on room air
Abdominal: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly
Extremities: Warm and well perfused extremities, lower extremities tender to palpation bilaterally, no pitting edema in extremities bilaterally
Neurologic: Alert, oriented to person/place/time, no focal deficits, no asterixis
Psychiatric: Calm, pleasant
Skin: Warm, dry
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Case 4 Index
Case 4 Introduction