Vital Signs: Temperature 98.3°F, Blood Pressure 119/89 mmHg, Heart Rate 120 beats/min, SaO2 98% on room air, Respiratory Rate 18 breaths/min
General Appearance: In mild respiratory distress
HEENT: Normal conjunctiva, no scleral icterus, dry mucous membranes, clear oropharynx
Lymph: No cervical lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no murmurs/rubs/gallops
Pulmonary: Tachypneic, lungs clear bilaterally
Abdominal: Soft, normal bowel sounds, no scars, non-distended, nontender
Extremities: warm and well perfused, no peripheral edema
Neurologic: alert, oriented, no focal deficits
Skin: Warm, dry, no rash
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Case 51 Index
Case 51 Introduction