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PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 36.1, heart rate 100, respiratory rate 18, blood pressure 142/74, oxygen saturation 96% on room air.
GENERAL: The patient is alert and oriented x3, does not appear to be toxic, but does appear dehydrated and uncomfortable.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, reactive to light. Extraocular movements are intact. Oropharynx is clear and dry.
NECK: Supple. No lymphadenopathy, JVD, or thyromegaly.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Tachycardic, regular rhythm.
CHEST: No retractions or reproducible tenderness.
BACK: No costovertebral angle tenderness.
ABDOMEN: Soft, nondistended, normal bowel sounds. Mild discomfort within the mid‑epigastrium to deep palpation. There is no rebound, no guarding, no masses, no right upper quadrant tenderness or hepatosplenomegaly.
EXTREMITIES: 2+ pulses, no edema.
SKIN: Warm, dry, no rashes.
NEUROLOGIC: Cranial nerves 2-12 intact, moves extremities equally, no focal findings.
GU/RECTAL: Deferred.
PSYCHIATRIC: Normal affect.