Case 8.2

On physical exam the following was noted:

VitalsBP 102/61 | Pulse 95  | Temp 36.2 °C (97.1 °F)  | Ht 172.7 cm (5′ 8″)  | Wt 59.9 kg (132 lb)  | SpO2 97%  | BMI 20.07 kg/m²  
ConstitutionalChronically ill-appearing man, pale, thin, no acute distress.
RespiratoryNormal respiratory effort, clear to auscultation
CardiovascularRapid rate, regular rhythm, no murmurs rubs or gallops
GastrointestinalHyperactive bowel sounds, soft, scaphoid,  nontender, nondistended, no masses, no hepatosplenomegaly, no guarding, no rebound
PsychiatricOriented to time, place, and person.  Normal mood and affect.  

 

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