History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Relevant Next Steps
Test Results
Interim Differential Diagnoses
Relevant Next Steps 2
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Anemia in a 42-year-old woman
Physical Examination
General appearance
: She appears tired but in no apparent distress.
Vital signs
:
Temperature: 37° C
Pulse: 85/min
BP 120/75 mm Hg
Respirations 15/min
Weight 78 kg
Height 163 cm
Skin
: No rashes or cyanosis.
HEENT
: Conjunctivae pale, no scleral icterus, no cervical adenopathy.
Pulmonary
: Lungs are clear to percussion and auscultation. No wheezes, rales, or rhonchi.
Cardiovascular
: No jugular venous distention at 45°. Normal heart rate and regular rhythm; S1 and S2 normal; no murmurs, rubs, or gallops.
Gastrointestinal
: Abdomen soft, nontender, spleen palpable and slightly enlarged, no hepatomegaly. No masses on rectal examination; stool is brown and heme-negative.
Genitourinary
: Pelvic examination shows no bleeding, masses, or visible lesions.
Musculoskeletal
: Joints and extremities normal.
Neurologic
: No focal findings
Mental status
: Alert and oriented, with appropriate affect and responses.
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