Vital Signs: Temperature 98.2°F, Blood Pressure 125/90 mmHg, Heart Rate 96 beats/min, Respiratory Rate 28 breaths/min, SpO2 = 100%
General Appearance: tired appearing, generalized pallor
HEENT: wearing glasses, normal conjunctiva, no scleral icterus, dry mucous membranes, clear oropharynx
Lymph: No cervical lymphadenopathy
Cardiovascular: normal S1, S2, regular rhythm, no rubs/murmurs/gallops
Pulmonary: Breath sounds normal bilaterally, no rales/rhonchi/wheezes
Abdominal: present bowel sounds, generalized tenderness to palpation without rebound or guarding, costovertebral angle tenderness bilaterally, no hepatosplenomegaly
Extremities: warm and well perfused, +1 non-pitting edema in bilateral lower extremities to mid-shin
Neurologic: Alert, oriented x3, answering questions appropriately
Psychiatric: able to interact well
Skin: Warm, dry, non-blanching erythematous rash on abdomen
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Case 56 Index
Case 56 Introduction