Vital Signs: (prior to intubation) Temperature 98°F, Blood Pressure 90/60 mmHg, Heart Rate 115 beats/min, Respiratory Rate 24 breaths/min
General Appearance: Intubated, unresponsive without sedation
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx. Pupils round and reactive to light.
Lymph: No cervical lymphadenopathy
Cardiovascular: Jugular venous distension (JVD) appreciated, tachycardic, split S2 with respiratory variation;
Pulmonary: Diminished breath sounds bilaterally, no wheezes, rhonchi, or rales
Abdominal: Soft, non-distended, non-tender
Extremities: No peripheral edema in extremities, extremities warm, no cyanosis
Neurologic: Unresponsive without sedation
Skin: Warm, dry, no rash
Access: Right femoral tunneled dialysis catheter with clean exit site; No drainage present; Multiple upper extremity arteriovenous accesses (AVF, AVG) bilaterally without thrill or bruit.
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Case 31 Index
Case 31 Introduction