Physical Exam

  • Weight - 13.5 pounds
  • Temperature - 102.5° F
  • Cardiovascular - WNL
  • Respiratory - increased lung sounds cranial-caudal
  • Hydration - 5 -7 % dehydrated
  • Ocular - WNL
  • Head and Neck - gingivitis, bad breath
  • Integumentary - WNL
  • Abdomen/Digestive - Painful abdomen, severe abdominal distention, resented palpation
  • Urogenital - increased urination
  • Nervous - WNL
  • Musculoskeletal - WNL
  • Lymph nodes, swelling - WNL

Assessment of history and physical exam?

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