History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Next Steps
Test Result 1
Question 1
Question 2
Question 3
About the Case
Cough in 47-yr-old woman
Physical Examination
General appearance
: Well-appearing woman; not in respiratory distress.
Vital signs
:
Temperature: 36.8° C
Pulse: 79 beats/min
BP: 133/88 mm Hg
Respirations: 15/min
Pulse oximetry: 95% on room air
Skin
: No cyanosis, rashes, or other lesions.
HEENT
: Anicteric sclerae, pupils equally round and reactive to light. No nasal polyps. Oropharynx clear, no postnasal drip. No lymphadenopathy.
Pulmonary
: Normal respiratory effort. Good air entry and exit but bilateral wheezing noted during forced expiration. No crackles or rhonchi.
Cardiovascular
: Normal rate, regular rhythm. No murmurs, rubs, or gallops. Jugular venous pressure not elevated.
Gastrointestinal
: Soft, nontender, nondistended abdomen with normal bowel sounds.
Genitourinary
: Not assessed
Musculoskeletal
: Tender to palpation at the junction of the sternum and right 3rd and 4th ribs. No swelling, redness, or tenderness in the legs.
Neurologic
: Normal gait with no focal deficits in strength or sensation.
Mental status
: Appropriate. Alert and oriented.
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