REVIEW OF SYSTEMS

GENERAL SURVEY Patient was awake with no changes in level of

consciousness, oriented to time, place, and to
people around her. Speech is not slurred. She
is fairly groomed with no evidence of weight
loss has body weakness noted, no loss of
appetite. Has edema on the periorbital area.

SKIN Skin has no jaundice with good skin turgor.

With lesions on the left leg and orbital area
noted.

HEAD Head is proportional and symmetrically

round, hard, smooth, and in midline to the
client’s body without lesions or bumps. No
tenderness upon palpation

EYES Patient experienced blurring of vision Sclera

are unicteric. She experienced periorbital
swelling, tenderness, and purulent drainage.

EARS No tenderness, and no abnormal discharges

noted.

CARDIOVASCULAR Patient has normal pulse rate (100 bpm). No

palpitations, and no heart murmurs heard
upon auscultation.

NOSE AND SINUSES No discharge, no tenderness, and no lesions

noted

MOUTH AND THROAT Lips are pale and dry without lesions and
swelling. Buccal mucosa is pale in color.
Uvula is at the midline, and tonsils are not
inflamed. Tongue has a lesion and whitish
pigments on the side.

MUSCULOSKELETAL No muscle and joint pain noted

RESPIRATORY Patient has normal Respiratory rate (20cpm)

with symmetric chest expansion. No
adventitious sounds heard upon auscultation.

GASTROINTESTINAL There is tenderness noted upon palpation. No

masses and lesions noted.

GENITOURINARY Lochia Serosa reported and voids about 3-5

times a day; but no pain, no polyuria, and no
oliguria noted.

HEMATOLOGY No bruises and no bleeding tendencies.

NERVOUS There is no decreased level of consciousness.
No numbness, no headache, and no tremors
noted.
PHYSICAL EXAMINATION

UPON ADMISSION DURING DUTY

(FEB. 11, 2018) (FEB. 19, 2018)

Blood pressure: 130/80 mmHg Blood pressure: 120/60 mmHg

HR: 100 bpm HR: 98 bpm

RR: 20 cpm RR: 20 cpm

Temperature: 36.6 ° C Temperature: 37.4 ° C

SKIN Skin has no jaundice, warm and dry to touch

with good skin turgor. Hair is evenly
distributed and capillary refill is immediate
(<3 sec.). With lesions on the left leg and
orbital area noted.

HEAD Head is proportional and symmetrically

round, hard, smooth, and in midline to the
client’s body without lesions or bumps. No
tenderness upon palpation.

EYES Eyeballs are symmetrically aligned in sockets

without protruding or sinking. Bulbar
conjunctiva is clear and moist; and palpebral
conjunctiva is pinkish and swollen noted.
Sclera is anicteric without increased
vascularity or lesions noted. Pupils equally
round and reactive to light and
accommodation. Eyebrows are symmetrical,
fine and black in color. Eyelashes are also
fine, black in color and is oriented outwards.
EARS Ears are equal in size bilaterally. Bilateral
auricles, tragus, mastoid processes are non-
tender. No abnormal discharges noted. Only
small amount of odorless cerumen observed.

NOSE Nose is patent and uniform in color without

deformity. Nasal septum is at the midline
without bleeding and deviation. No discharge,
tenderness, and lesions noted.
MOUTH AND THROAT Lips are pale and dry without lesions and
swelling. Buccal mucosa is moist and pale in
color. Uvula is at the midline, and tonsils are
not inflamed.

NECK Neck is supple. Trachea is at the midline, and

no cervical lymphadenopathy and masses
noted.

CHEST AND LUNGS Patient has normal Respiratory rate (20cpm)

with symmetric chest expansion. No
adventitious sounds heard upon auscultation.

CARDIOVASCULAR Heart has a normal rate (98 bpm) and has

regular rhythm. No murmuring heart sounds
and thrills auscultated.

BREAST Breast is symmetric and no abnormal

discharges noted

ABDOMEN There is tenderness upon palpation. No

masses and lesions noted. No diarrhea and
constipation noted.

EXTREMITIES All extremities have no edema. No active

lesions noted.

NEUROLOGIC There is no decreased level of consciousness,

no numbness, no tremors and no tingling
sensation noted.