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Vitals: Temperature = 98.4; Respiratory Rate = 14 per minute; Heart Rate = 76 bpm (lying), 78 bpm (sitting) and 80 bpm (standing); Blood Pressure = 122/72 (lying), 118/68 (sitting) and 116/64 (standing). Weight = 120 lb. (down from usual 130 lb.)
General: Well developed, well nourished, thin white female in no acute distress.
HEENT: Head without lesions, sclerae and conjunctivae normal, tympanic membranes clear with small amount of fluid bilaterally. Nose without lesions or signs of recent bleeding. Pharynx without erythema or exudates or lesions. Back teeth appear normal, breath has odor of ketones. Teeth in general appear yellowed.
Chest (Pulmonary): Lungs auscultate and percuss clear throughout. No chest wall or CVA tenderness elicited.
Heart: Regular rate, no murmurs, rubs or gallops noted. PMI not displaced.
Abdomen: Liver percusses 8 cm in the mid-clavicular line, edge non-tender. Epigastric region tender to palpation, no masses appreciated. Spleen tip not palpable. Remainder of abdomen without masses or guarding or rebound. No masses appreciated throughout. Rectal exam notable for heme positive brown stool in the vault.
Genitourinary: External genitalia within normal limits; Bartholin's glands and urethra also appear normal. Introitus without lesions, vault with scant clear discharge. Cervical os nulliparous, no erythema or discharge. PAP, Gonorrhea and Chlamydia cultures sent. Bimanual exam notable for "baseball-sized" nontender uterus, anteverted, retroflexed. Adnexae without masses or tenderness.
Neurologic: Cranial nerves II - XII grossly intact, cerebellar grossly intact. Deep tendon reflexes not tested.
Skin: Intact. Not diaphoretic.
Extremities: Pulses 2+ throughout. Capillary refill less than 2 seconds.