Vital Signs: Temperature 99.0°F, Blood Pressure 175/105 mmHg, Heart Rate 95 beats/min, Respiratory Rate 15 breaths/min
General Appearance: No acute distress
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx; no papilledema
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Pulmonary: Bibasilar crackles, no wheezes or rhonchi, mildly labored breathing
Abdominal: soft, non-tender, normoactive bowel sounds, no hepatosplenomegaly, gravid uterus
Extremities: warm and well perfused, trace edema of bilateral lower extremities
Neurologic: Alert, awake, answers appropriately
Psychiatric: Calm, pleasant
Skin: Warm, dry
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Case 37 Index
Case 37 Introduction