Case 2 Index
Vital Signs: BP 125/78, HR 81, T 36.6 (97.8F), RR 10, SpO2 = 98%, BMI 25.7
General Appearance: Well-appearing female in no distress
HEENT: No ocular inflammation. Temporal arteries are nontender with a palpable pulse bilaterally.
Lymph: No lymphadenopathy.
Cardiovascular: No murmurs, rubs, or gallops. No carotid bruits. Radial, brachial, dorsalis pedis, and posterior tibialis pulses were 2+.
Pulmonary: lungs clear to auscultation bilaterally.
Abdominal: bowel sounds present, soft, nontender, nondistended, no hepatomegaly, no splenomegaly
Extremities: warm and well perfused extremities, no pitting edema.
Neurologic: alert and oriented x3. No light perception in the left eye. No other focal deficits noted.
Psychiatric: Calm, pleasant
Skin: No rashes or purpura.
Retinal exam: evidence of anterior ischemic optic neuropathy OS
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