Vital Signs: Temperature 98.2°F, Blood Pressure 134/76 mmHg, Heart Rate 77 beats/min, Oxygen Saturation 96% on room air
General Appearance: In no acute distress. Awake and alert middle-aged man
HEENT: EOMI, +icteric sclera, no conjunctival injection
Lymph: No cervical lymphadenopathy
Cardiovascular: Regular rate and rhythm, no rubs/murmurs/gallops
Pulmonary: Clear to auscultation bilaterally. Breathing comfortably on room air
Abdominal: No scars appreciated on inspection, soft, non-distended, mild tenderness to palpation in RUQ and epigastrium, +Murphy sign
Extremities: Warm and well perfused extremities, no pitting edema
Neurologic: Alert and oriented, no focal neurological deficits
Psychiatric: Calm, pleasant
Skin: Warm, no rashes, dry
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Case 6 Index:
Introduction