Case 3: Physical Exam

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Physical exam

Vital Signs: T 37.5°C, HR 101, BP 105/95, RR 19, 98% on RA
General Appearance: tired-appearing young woman
HEENT: no alopecia, +conjunctival pallor, +~ 3mm ulcer with yellowish base and an erythematous halo noted on hard palate
Lymph: No lymphadenopathy
Cardiovascular: no JVD, tachycardic to 100 bpm, regular rhythm, no murmurs, 2 component pericardial friction rub heard under the L breast; best auscultated when laying down, and disappearing when upright
Pulmonary: clear to auscultation
Abdominal: bowel sounds present, soft, nontender, nondistended, no hepatomegaly, no splenomegaly
Extremities: warm and well perfused extremities, no pitting edema
Neurologic: alert and oriented x4, strength 5/5 in all extremities, sensation to light touch intact, normal gait
Psychiatric: Calm, pleasant
Skin: erythematous plaques on cheeks and nose with sparing of the nasolabial folds
(source: DermNet NZ, click on image to go to link)
Malar rash from DermNet NZ

MSK: as illustrated below via RheumSimBot©

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