Physical Exam Findings: VITAL SIGNS: Temperature: 37.2°C…
Physical Exam Findings: VITAL SIGNS: Temperature: 37.2°C (98.9°F) Pulse rate: 80 bpm Respiration Rate: 18/min Blood pressure: 126/80 mmHg. Oxygen saturation: 99% on room air Weight: 79.5 kg (175 lb) Height: 182 cm (72 in) GEN: Well-developed, well-nourished female. Appears in no acute or general distress. Alert and oriented x 4, answering questions appropriately. HEENT Atraumatic, normocephalic. Ear canals clear bilaterally, TMs pearly gray with no bulging or defect noted. Nares patent, septum intact. Lips and gingiva normal in appearance, posterior pharynx without erythema or exudates. PERRLA, EOMI B/L. NECK: Neck is supple, no masses, trachea midline, no thyroid nodules, masses. No lymph node tenderness or enlargement. SKIN: No bruising, cyanosis, or pigment changes appreciated, without obvious lesions or rashes. Normal hair pattern. HEART: Regular rate, regular rhythm with normal S1, S2, without rubs, murmurs or gallops auscultated. No peripheral edema noted. No JVD. LUNGS: Clear to auscultation B/L. No adventitious breath sounds. No increased respiratory effort appreciated. No wheezing, rales, rhonchi, or stridor. PERIPHERAL VASCULAR: Capillary refill WNL throughout extremities, < 2s. No peripheral edema. Pulses 2+ and intact at DP, PT, brachial and radial B/L. No digital clubbing noted. ABD: Normoactive bowel sounds heard throughout all quadrants. Soft, non-distended abdomen without tenderness to light or deep palpation. No rebound or guarding noted. No hepatosplenomegaly noted. No abdominal bruits or pulsatile masses. No CVA tenderness elicited B/L. The bladder does not feel distended on palpation. No masses appreciated on deep palpation. GU/Rectal: Pelvic exam reveals pink, multiparous, non-friable cervix. No discharge, CMT, or bleeding from closed cervical os. No appreciable mass or deformity. Vaginal canal without blood present throughout. No inguinal LAD appreciated. Rectal exam reveals normal sphincter tone. No hemorrhoid, mass, or lesions noted externally. Hemoccult testing negative. NEURO: Pt alert and oriented x 4, following commands appropriately. Speech clear and without slurring. No facial asymmetry. Gait steady and without limp or need for assistance. Strength 5/5 in all extremities and major muscle groups, equally throughout B/L sides. No sensory deficit appreciated throughout extremities. PSYCH: Affect and mood normal. Judgment and insight intact; no confusion. No homicidal or suicidal ideation. No pressured or tangential speech. No evidence of hallucinations. Diagnostic Results: CBC WBC 8.2 RBC 4.5 Hgb: 13.2 Hct 36.9% MCV 85 MCHC 29 Platelets 300 Neutrophils 56% Lymphocytes 30% Monocytes 6% Eosinophils 3% Basophils 1% 4.0-11.0 3.9-5.1 12-16 35-45% 80-100 27-34 150-450 40-60% 20-40% 2-8% 1-4% 0.5-1% CMP Sodium 138 mmol/L Potassium 4.1 mmol/L Chloride 100 mmol/L CO2 24 mmol/L BUN 18 mg/dL Creatinine 0.9 mg/dL Glucose 114 mg/dL Calcium 9.1 mg/dL Alk phos 48 U/L ALT 20 U/L AST 19 U/L Albumin 4.4 g/dL Total Protein 7.1 g/dL Total bilirubin 0.9 mg/dL 135-145 mmol/L 3.5-5 mmol/L 96-106 mmol/L 20-30 mmol/L 6-20 mg/dL 0.6-1.3 mg/dL 60-126 mg/dL 8.5-10.2 mg/dL 20-130 U/L 4-36 U/L 8-33 U/L 3.4-5.4 g/dL 6.0-8.3 g/dL 0.1-1.2 mg/dL PT/INR PT: 11.2 INR: 1.0 PT: 11-13.5 seconds INR: 1-1.2 aPTT 25 seconds 22–39 seconds Urinalysis and microscopy Color: Yellow Appearance: Clear Leukocyte esterase: 0 Nitrites (mg/dL): 0 Urobilinogen (mg/dL) 0.9 Protein (mg/dL): 40 pH: 6.8 Blood (mg/dL): 0.250 Specific gravity: 1.01 Ketones (mg/dL): 0 Bilirubin (mg/dL): 0 Glucose (mg/dL): 0 RBC: 50/hpf WBC: None/hpf Squamous epi cells: 3/hpf Bacteria: None seen Mucus: Trace Clear to yellow Clear 0 (Negative) 0 mg/dL (Negative) 0.2-1 mg/d/L 0-20 mg/dL 4.6-8.0 0-0.02 mg/dL 1.005-1.030 0 mg/dl (Negative) 0 mg/dl (Negative) 0 mg/dl (Negative) 0-4 / hpf 0-4 / hpf 0-3 / hpf None None to trace Urine Gram Stain and Culture Preliminary gram stain reveals no bacterial growth; Final (full) culture and sensitivity results are pending No bacteria seen (gram stain); No bacterial growth (culture) Urine NAAT STI Panel(gonorrhea, chlamydia, trichomoniasis) Negative; Negative; Negative Negative; Negative; Negative 24-hour urine protein 140 mg/dL per 24 hours