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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
Copyright:Attribution Non-commercial


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General: She has gained about 8 lbs in the past 2 years.Skin: No skin rashes and fair skinned.HEENT:
No history of head injury. Has intermittent headache. 
Has reading glasses for 2 years and currently not usingit. 
 Ears :
Hearing is good. No tinnitus and infection 
No discharges noted and sinuses were not inflamed 
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 &:
 No skin retractions and thorax isLungs symmetric with good excursion
 No palpable masses.
Right lung is more resonant than the left.
 No wheezingCardio:
 No irregular bulging.
Apical impulse discrete and tapping, barely palpable in the 5
left interspace midclavicular line
It is dynamic without heaves and thrills. NormalS1 & S2 and no murmurs heard.Breast:
 No skin retractions, breast is symmetrical, nonipple discharges.
 No masses and lymph nodes were palpated.Abdomen:
 No surgical scars were seen and abdomen is flat.
 No irregular bowel sounds were heard.
Dull on the right upper quadrant where liver islocated and most of the areas are tympanitic.
Spleen and liver are not palpable.Extremities:No varicosities, edema and it is warm to touch. Calves are nonTender 

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