• VITAL SIGNS
BP: 112/ 60, HR: 92, RR; 20, O2 sat 100%, weight: 60 kg (132 lbs) , Height:5’6” , BMI: 21.3
General appearance: uncomfortable appearing thin young woman
HEENT: Normal conjunctiva, no scleral icterus, dry mucous membranes, clear oropharynx
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Respiratory: clear bilateral breath sounds
Abdominal: moderately distended abdomen with fullness in the RLQ, mild diffuse tenderness but no guarding or rebound, hypoactive bowel sounds
Extremities: warm and well perfused extremities, 1+ bilateral pitting edema to shins bilaterally
Neurologic: Alert, Oriented X 3 with no focal deficits
Psychiatric: Calm, pleasant
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