The head and neck are nontender without thyromegaly or adenopathy. HEENT AND NECK: The head is normocephalic and atraumatic. ![]() SKIN: No skin rashes or lesions are noted. Her body habitus is ectomorphic and she is markedly asthenic. GENERAL: The patient appears older than her stated age. In fact, pulses were good and there was no groin adenopathy other than swelling, which was present before. ![]() The right leg was not warm, hot or tender. There was a wound that was draining some yellowish drainage on the left lower leg. There were no masses palpable and there was no distention, rebound or guarding.ĮXTREMITIES: The patient had swelling of both his legs. He had an ileostomy that was functioning. ![]() No heart murmurs.ĪBDOMEN: The patient was morbidly obese. Pulse 102, respirations 22 and blood pressure 132/78. VITAL SIGNS: Temperature in the ER was 100.6 degrees, has been 99.6 degrees since then, currently 98.4 degrees.
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