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Review of Systems General Skin Heent :

Review of Systems General Skin Heent :

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Published by unno hiquiana

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Published by: unno hiquiana on Feb 02, 2010
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05/17/2013

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REVIEW OF SYSTEMS
General: She has gained about 8 lbs in the past 2 years.Skin: No skin rashes and fair skinned.HEENT:
 Head:
No history of head injury. Has intermittent headache. 
 Eyes:
Has reading glasses for 2 years and currently not usingit. 
 Ears :
Hearing is good. No tinnitus and infection 
 Nose:
No discharges noted and sinuses were not inflamed 
Throat:
No bleeding gums were seen and has tonsillitis. Neck:Tender lymph nodes on the both tonsillar area. Nogoiter Breast:No lumps, discharges and nipple retractionsRespiratory:No cough, wheezing and history of TBCardiovascular:No heart diseases and hypertension.GI:Appetite is good. Experienced nausea and vomiting prior to admission. Bowel movement about once daily,no diarrhea and bleeding. No jaundice and live problemsUrinary:No frequency, dysuria, hematuria or recent flank pain.Genital:No vaginal or pelvic infection. No dyspareuniaPeripheral Vascular:No history of leg painPsychiatric:No history of depression or psychiatric treatment Neurologic:Memory is good. Had dizziness recentlyHematologic:Has anemia 
Physical Examination
Mr. Sigampong is a medium built man who responds quickly toquestions. He is in pain and anxious on the medications given. His hair is fixedand neat. He is more comfortable in sitting position.Vital signsBP : 80/60 mmHgHR : 72 bpmRR : 24 cpmTemp. : 36.0 CSkin: Fair skinned and palms are cold. Nails without cyanosisand clubbingHead: Hair of average texture;Scalp – no lesions and normocephalicEyes: Visual acuity of 20/30 on the left eye; 20/25 on the rightVisual fields full by confrontationConjunctiva pink; sclerae are white.Pupils are round, regular and equally reactive to light.Ears: Waxes partially obscure both tympanic membranes. Goodacuity to whispered voice. AC BC. Weber is on the midline. Nose: No mucosal discharges and sinus tendernessThroat: Tongue in midline position, inflamed left tonsils with exudates Neck:Trachea is midline. No palpable mass.
 
Lymph nodes:Lymph node tenderness on left tonsillar and both periauricular areasThorax &:
Inspection:
 No skin retractions and thorax isLungs symmetric with good excursion
 Palpation:
 No palpable masses.
 Percussion:
Right lung is more resonant than the left.
 Auscultation:
 No wheezingCardio:
Inspection:
 No irregular bulging.
 Palpation:
Apical impulse discrete and tapping, barely palpable in the 5
th
left interspace midclavicular line
 Auscultation:
It is dynamic without heaves and thrills. NormalS1 & S2 and no murmurs heard.Breast:
Inspection:
 No skin retractions, breast is symmetrical, nonipple discharges.
 Palpation:
 No masses and lymph nodes were palpated.Abdomen:
Inspection:
 No surgical scars were seen and abdomen is flat.
 Auscultation:
 No irregular bowel sounds were heard.
 Percussion:
Dull on the right upper quadrant where liver islocated and most of the areas are tympanitic.
 Palpation:
Spleen and liver are not palpable.Extremities:No varicosities, edema and it is warm to touch. Calves are nonTender 
Diagnosis:
Tonsillitis

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