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​​Vital Signs​

  • Weight = 118 lbs (53.5 kg)

  • Height = 60 in (1.5 m)

  • BMI = 23.5 kg/m

  • Temp: 97.8°F (36.6°C)

  • Blood pressure = 124/76 mm Hg

  • Pulse oximetry = 98% on room air  

 

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2

​Physical Examination​

  • Abdominal distension, “it’s uncomfortable to sit sometimes”

  • Early satiety, nausea

  • No edema, jaundice

  • No diarrhea, hematochezia, or melena

  • History of recurrent urinary tract infections (3)

  • No cervical lymph node enlargement 

  • No wheezing or adventitious sounds

  • No focal neurologic signs or confusion

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Psychiatric ​

  • Euthymic, affect normal, alert and oriented

  • Reports “being nervous a lot,” occasional has “a racing heart.”

  • General Anxiety Disorder-7 score = 10 (moderate anxiety)

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