Case 38: Physical Exam

Case 38 Index

Vital Signs: Temperature 100.0°F, Blood Pressure 100/65 mmHg, Heart Rate 110 beats/min, Respiratory Rate 16 breaths/min
General Appearance: No acute distress, thin
HEENT: Normal conjunctiva, no scleral icterus, dry mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, tachycardic, no rubs/murmurs/gallopsstethoscope
Pulmonary: Clear to auscultation bilaterally, no wheezes/rhonchi/rales
Abdominal: soft, non-tender, normoactive bowel sounds, no hepatosplenomegaly
Extremities: warm and well perfused, no edema
Neurologic: Alert, awake, answers questions appropriately
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash

What’s at the top of your differential diagnosis? Choose 3 before moving on!
Cardiorenal syndrome
Hepatorenal syndrome
Minimal change disease
Acute tubular necrosis (ATN)
Tumor lysis syndrome (TLS)
Acute interstitial nephritis (AIN)
Thrombotic microangiopathy (TMA)
Retroperitoneal fibrosis
Leukemic infiltration

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