70 BPM 18 RPM on 2 L of NC
Gen: Mr.**** is a ill appearing WD/WN middle aged African American male that appears his stated age who is in mild acute distress, exhibiting moderate pain with deep respiration, & moderate discomfort. The patient is A&O x 4, is cooperative throughout the interview with appropriate responses.
HEENT: NCAT, symmetrical facial features with appropriate expression of affect, anicteric conjunctiva without pallor, PERRLA, EOMI, no rhinorrhea, MMM
Pulm: Positive for accessory muscle use, speaking in full sentences, no audible wheezes on approach, rhonchi in the upper left & right lobes, no consolidation or rales appreciated
Cardio: No JVD or carotid bruits, RRR, normal S1 & S2, no click/murmur/rub/gallop
Abdomen: Non-distended obese, without voluntary or involutary guarding, bowel sounds present, nontender to light & deep palpation, no fluid wave
Extremities: Symmetric without deformity, no edema at this time, no clubbing/cyanosis, warm well perfused & dry to the touch with symmetrical 2+ radial & dorsalis pedis pulses
Neuro: CNII-XII grossly intact
How many organ systems are you counting? I am only counting 7