Vital Signs: Temperature 96.8℉, Blood Pressure 102/54mmHg, Heart Rate 107 beats/min, Respiratory Rate 22 breaths/min
General Appearance: Lethargic woman, no acute distress
HEENT: No conjunctival icterus, moist mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, tachycardic, regular rhythm, no rubs/murmurs/gallops
Pulmonary: lungs clear to auscultation bilaterally
Abdominal: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly
Extremities: warm and well-perfused extremities, no pitting edema
Neurologic: Alert and oriented to person, place, and time, no asterixis
Psychiatric: Flat affect
Skin: Warm, no rashes, dry, no jaundice
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