Vital Signs: Temperature 98.5°F, Blood Pressure 119/72 mmHg, Heart Rate 80 beats/min, Respiratory Rate 14 breaths/min
General Appearance: In no acute distress
HEENT: Normal conjunctiva, no scleral icterus, clear oropharynx, moist mucous membranes
Lymph: No cervical lymphadenopathy
Cardiovascular: regular rhythm, no rubs/murmurs/gallops
Pulmonary: normal respiratory effort, clear lung fields bilaterally, no wheezes, rhonchi, or rales
Abdomnal: soft, non-distended, non-tender, mild left costovertebral angle (CVA) tenderness
Extremities: no peripheral edema in lower extremities, all extremities warm, no cyanosis
Neurologic: Alert, awake, answers appropriately
Psychiatric: Normal mood and affect
Skin: Warm, dry, no rash
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Case 32 Index
Case 32 Introduction