Vital Signs: Temperature 99.2°F, Blood Pressure 180/110 mmHg, Heart Rate 73 beats/min, Respiratory Rate 13 breaths/min
General Appearance: In no acute distress
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Pulmonary: Breath sounds normal bilaterally, no rales/rhonchi/wheezes
Abdominal: non-tender or distended, soft, no scars
Extremities: warm and well perfused, +3 pitting edema of lower extremities to shins bilaterally
Neurologic: Alert, awake, answers appropriately
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash
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Case 35 Index
Case 35 Introduction