Review of Systems:

General  Toothache (Left molar tooth)

 Fever
 Fatigue Breast
 Weakness  Lumps
 Recent weight change  Pain
 Nipple discharge
Integumentary
 Rash Respiratory
 Erythema  Dyspnea
 Pruritus  Cough
 Hair and nails changes  Chest pain
 Changes in sizes and color of moles  Hemoptysis
 Wheezing
Head and Neck
 Headache (2/10) Cardiovascular
 Dizziness  Dyspnea
 Injury  Orthopnea
 Easy fatigability
Eyes  Edema
 Pain  Palpitation
 Redness  Chest pain
 Loss of vision  Paroxysmal nocturnal dyspnea
 Itching
 Dryness Gastrointestinal
 Excessive lacrimation  Nausea
 Corrective lenses  Vomiting
 Constipation
Ears-Nose-Throat-Mouth  Diarrhea
 Tinnitus  Abdominal pain
 Loss of hearing  Hematemesis
 Otalgia  Hematochezia
 Otorrhea  Flatulence
 Epistaxis
 Anosmia Genitourinary
 Hoarseness  Dysuria
 Dysphagia  Frequency
 Sore throat  Dribbling
 Bleeding gums  Discharge
 Loss of taste  Hematuria
 Dryness of mouth
 Sores/patches in mouth Musculoskeletal
  Myalgia Endocrine
 Arthritis  Weight change
 Weakness on his left knee but  Heat and cold intolerance
tolerable  Hyperhidrosis
 Joint stiffness  Polydipsia, polyphagia, polyuria
 Cramps
 Backache Nervous
 Headache
Hematologic  Syncope
 Anemia  Seizure
 Easy bruising  Weakness
 Bleeding  Numbness
 Memory loss

Physical Examination
GENERAL: Patient is a young, healthy looking male, about 5 feet tall. Alert. Answers our question
coherently. No malodorous scent, hair length was not assessed due to the bandage on his head.
Hospital gown. Patient is on sitting position. Pt was not asked to walk. Gait was not assessed. Has no
involuntary movement or gross deformity and slightly in pain (headache) 4/10. He has a dark
complexion. Abrasions on the wrist area 3 cm x 51.5 cm, 2 abrasions on the popliteal area. 1 cm
abrasion on the right eye, abrasions on the right temporal area (4 x 3 cm)

Vital signs

1. Blood Pressure: 110/80

2. Heart Rate & Rhythm
a. Pulse rate: 70
b. Cardiac Auscultatory Rate: 67 bpm
3. Respiratory Rate, Depth and Regularity
17 bpm, regular rhythm
4. Temperature: 36.3 C

5. Pain Scale: --

SKIN

Skin is dark complexion, slightly cold to touch.

HEAD, EYES, EARS, NOSE, THROAT & NECK

Head: Face is symmetrical with no involuntary movements while skin is dark.

**PE on the head was not fully assessed because gauze is drained with blood and delicate-looking.
The Eyes: symmetrical eyebrows, equally distributed hair. Symmetrical eyelids. White sclera and
pink palpebral conjunctiva, clear cornea and lens. Pupils are reactive to light. No visual defects noted
on confrontation test. Intact EOM. No hemorrhage or exudates noted

The Ears: Symmetrical ears, non-tender auricle.

The Nose: Symmetrical nose, nasal pages are patent, septum at midline.

The Throat: Dry lips, without lesions, reddish oral mucosa, pinkish gum, white teeth, hard palate Is
high arch. Symmetrical tongue in protrusion, uvula at midline. Tonsils are enlarged reddish pharynx
with no lesions

The Neck: neck is non-tender with no palpable mass or lymph adenopathy, Thyroid is diffusely
enlarged, firm, non-tender and moves deglutition, no bruit noted. Trachea is on midline

CHEST AND LUNGS

Thorax is symmetrical in expansion, no deformity. No widening ICS, no retractions. No visible mass.

Quiet breathing. Without pain. No rales, wheezes or rhonchi.

CARDIOVASCULAR

No bluging of precordum, absence of lesions, thrills, heaves or lift and tenderness

GASTROINTESTINAL:
Symmetrical, globular in shape, abdominal movement is synchronized with respiratory breathing.
No visible pulsations, no peristaltic movement, umbilicus is midline and inverted.

Bowel sounds are 5/min. No borborygmus. No bruits, no friction rubs on hepatic or spleenic areas

Tympanic in all quadrants, liver span is on midclavicular line right. Traube’s space is not obliterated
and negative kidney punch test

On light palpation, abdomen is soft in all quadrants, no area of tenderness, superficial masses or
organ. On deep palpation, liver has smooth with regular borders. No rebound tenderness. No deep
masses. no organomegaly

(-) fluid wave test, no shifting dullness. Upon palpation on appendix, there is no rebound and direct
tenderness, (-) raving’s sign, (-) psoas sign, (-) obrturator sign, no cutaneous hyperesthesia. (-)
murphy’s sign

MUSCULOSKELETAL:

MUSCULOSKELETAL
Temporomandibular joint: Symmetrical face, no swelling, no redness of joint, non-tender
joint. Smooth range of motions.

Shoulder: Symmetrical with intact bony structures. No swelling, redness

or deformity noted. No tenderness noted. Can do shoulder
movement as to flexion and extension, abduction and
 adduction and internal and external rotation without
difficulty
Elbow: Intact medial and lateral epicondyle and olecranon processes,
non-tender not swollen; can do flexion, extension, and
supination and pronation without difficulty

Wrist and hands: Hand movements are smooth and natural, no swelling nor
deformities noted. Can do flexion, extension, adduction and
abduction without difficulty.

Spine: Looking at the side, there is cervical and lumbar concavities

and thoracic convexity. Equal shoulder height. No skin lesion
or swelling noted. No tenderness or spasm noted.

Hip: No tenderness, swelling or body prominence abnormalities

noted. Gait is smooth with maintained balance with
symmetrical leg length

Knee: Symmetrical with no swelling or redness noted. No area of

tenderness. Can do flexion, extension, internal and external
rotation.

Ankle and foot: The surfaces are smooth with no obvious lesions. No swelling
or tenderness noted. Dorsalis pedis and posterior tibial pulses
are equal. Can do flexion and extension, inversion and
eversion without difficulty.

CENTRAL NERVOUS SYSTEM

Mental Status: Alert, relaxed, and cooperative. Oriented to person, place, and time. No illusion or
hallucinations. Knows what was done to him and recalls the main reason of his admission. His
responses to family or personal situation are appropriate. Cooperative and jolly.

Cranial nerves

I Can smell on both nostrils

II no visual defects on confrontation test. Fundoscopy was not done
III Both pupils reactive to light. Intact direct and conjugate papillary
reflex
III, IV, VI intact EOMs. No nystagmus, strabismus and ptosis noted
V Sensations on the face present. Temporal and masseter strength
intact. Can clench his teeth with positive corneal reflex on both eyes.
Blink both eyes normally.
VII symmetrical face can raise both eyebrows, can smile and frown and
puff out both cheeks
VIII – (-) Weber’ test, Rinne’ test, (AC>BC) on both ears. Can hear snapping
finger at a distance of 1 foot whispered words and rubbing of hair
strands
IX, X – Can swallow without difficulty. No dysphonia, no uvula deviation. Soft
palate rises symmetrically. Gag reflex present
XI – symmetrical, can shrug both shoulders, able to move head
XII – can protrude tongue. No tongue deviation
Cerebellar: can do tandem walking. Romberg’s test is negative

Meningeal: No nuchal rigidity, (-) Kernerg’s sign, (-) brudzinski’s sign