Vital Signs: Temperature 100.1°F, Blood Pressure 162/92 mmHg, Heart Rate 82 beats/min, Respiratory Rate 14 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: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly
Extremities: warm and well perfused extremities, trace pitting edema of bilateral ankles. Mild swelling and tenderness of bilateral wrists and ankles
Neurologic: Alert, Oriented x3, no focal deficits
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rashes
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Case 7 Index
Case 7 Introduction