History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Essential Immediate Steps 1
Test Interpretation
Interim Follow-up
Diagnosis
Essential Immediate Steps 2
Essential Immediate Steps 3
Question 1
Question 2
Question 3
About the Case
Fatigue and Palpitations in a 53-year-old Woman
Physical Examination
General appearance
: Slender middle-aged woman in no apparent distress.
Vital signs
:
Temperature: 37.2° C
Pulse: 58 beats/min
BP: 125/74 mm Hg
Respirations: 14/min
Oxygen saturation: 96% on room air
Skin
: No rashes noted.
HEENT
: Oropharynx clear.
Pulmonary
: Lungs clear to auscultation bilaterally. No wheeze, rhonchi, or rales.
Cardiovascular
: Regular rate and rhythm, normal S
1
and S
2
; no murmurs, rubs, or gallops. Brisk carotid upstrokes. No jugular venous distention.
Gastrointestinal
: Soft, nontender, nondistended abdomen; positive bowel sounds.
Genitourinary
: Unremarkable
Musculoskeletal
: Unremarkable
Neurologic
: Unremarkable
Mental status
: Unremarkable
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