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Review of Systems

Review of Systems

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Published by Danna Tan

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Published by: Danna Tan on May 08, 2011
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05/08/2011

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Systems Integumentary

Head

Respiratory Cardiovascular Musculo skeletal

Noted to be dragging left foot, muscle strength in left leg is 3/5 while on the right 4/5. Able to feel light touches but not all able to feel sharp and dull but makes mistakes sometimes Digestive No gross deformities, hypoactive bowel sounds Constipated unable to defecate for 3 days Urinary No pain during urination Need straining for urination hesitancy Plexus and Origin Nerves Assessment Cervical (C1-C4) Phrenic Client able to move from side to side and up and down Brachial( C5-T1) Axillary Radial Musculo cutaneous Ulnar Median Intercostal nerves(Thorax) Obturator Femoral Sciatic tibial Common Fibular Numb er 1 2 3 4 5 6 7 Name Olfactory Optic Oculomotor Trochlear Trigeminal Abducent Facial Able to raise hands and elbows, able to shrug Hands and arms able to extend muscle strength graded 5/5 both extremities Hands and arms able to flex muscle strength graded 5/5 both extremities Able to grasp object and flex fingers without difficulty Able to grasp object and flex fingers without difficulty Able to breath w/o difficulty, good shrug, able to raise hand w/o difficulty muscles in back are strong, abdominal muscles able to move Thighs able to push inside able to adduct graded4/5 on right leg 3/5 on left Thighs able to extend outward graded 4/5 on both extremities Able to dorsi flex of feet graded 4/5 on right leg 3/5 on left able to push leg muscle up Able to plantar flex graded 4/5 on right leg 3/5 on left Able to push lower leg down Assessment

Focus Health Assessment: Normal Skin fair noted moles and age spots no noted wounds. Nail beds clean. No pressure ulcers noted. skin turgor returns immediately when pinched Normocephalic head, hair long and clean no presence of lice or dandruff equally distributed. Anicteric sclerae pink conjunctive, pupil 3mm equal reactive to light 6 cardinal gazes intact, no facial asymmetry, gross hearing intact able to differentiate taste and smell uvula in midline tongue in midline Clear breath sound no difficulty in breathing no rales or wheezing noted. Equal chest expansion no gross deformities Distinct s1 s2 palpable pulses regular in rhythm Upper extremities graded 5/5 reflexes +2 able to walk with assistance

Abnormal

Not Applicable(T2-T8) Lumbosacral(L1-S4)

Able to differentiate vinegar from coffee scent Pupil 3mm Equal Reactive to light Able to close upper eyelid and able to follow 6 cardinal gazes, pupils able to constrict when light present Able to close upper eyelid and able to follow 6 cardinal gazes Able to chew food without difficulty Able to close upper eyelid and able to follow 6 cardinal gazes No facial asymmetry. Can differentiate salty to sweet taste, is able to cry and no problem in salivary glands

intact gross hearing Can swallow food without difficulty uvula in midline. Can differentiate salty to sweet taste Can swallow food without difficulty uvula in midline Able to turn head. Good shrug Tongue in midline.8 9 10 11 12 Vestibulocochl ear Glossopharyn geal Vagus Accessory Hypoglossal Air conduction greater than bone conduction. able to move tongue .

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