Case 4: Physical Exam

Physical exam

Vital Signs: T 36.6 C, BP 110/68, HR 67, SpO2 100% on RA

General Appearance: well-appearing
HEENT: no conjunctival injection or sclera icterus, no mouth/nasal ulcers, good salivary pooling
Lymph: No lymphadenopathy
Cardiovascular: normal rate, regular rhythm, no murmur, gallop, rub
Pulmonary: clear lungs bilaterally without adventitious sounds
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, 5/5 strength in upper and lower extremities
Psychiatric: Calm, pleasant
Skin: no rashes, nails without abnormalities, no nodules

MSK: as illustrated below via RheumSimBot©

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Case 4 Introduction
Case 4 Review of Systems