Case 5: Physical Exam

Vital Signs: Temperature 99.6°F, Blood Pressure 147/85 mmHg, Heart Rate 90 beats/min, Respiratory Rate 17 breaths/min, Oxygen Saturation 99%, BMI 32 kg/m2
General Appearance: Obese male in no acute distress
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rate and rhythm, no rubs/murmurs/gallops stethoscope
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, mod-severe left lower quadrant tenderness to palpation, mildly distended, normoactive bowel sounds, no rebound or guarding, no hepatosplenomegaly, no palpable masses
Extremities: Warm and well perfused extremities, no edema
Neurologic: Alert and oriented, no asterixis
Psychiatric: Normal mood and affect
Skin: Warm, no rashes, dry, no jaundice

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