REVIEW OF SYSTEMS

INTEGUMENTARY: no pruritus

CARDIORESPIRATORY: no cough, no colds, and no difficulty of breathing, no chest pain

GIT: no vomiting, no abdominal pain and no diarrhea

GUT: no oliguria, no dysuria, no hematuria

HEMATOLOGIC: no epistaxis and gum bleeding

MUSCOLOSKELETAL: no myalgia, body malaise and arthralgia, with body weakness

ENDOCRINE: no fever

CNS: no seizure and headache

PHYSICAL EXAMINATION

General survey:

The patient is sleeping, not in respiratory distress but weak looking.

Vital signs:

Temperature: 36.5 C (afebrile)

Heart rate: 148 bpm

Respiratory Rate: 40 cpm

Anthropometric measurement:

Weight: 2.4 kg

Length: 47cm

HC: 31 cm

CC: 29 cm

AC: 29 cm
Skin: pinkish, smooth, good skin turgor, warm to touch, no rashes, no bruises or hematoma

Head: no molding, open fontanels, no overlapping of sutures

Eyes: pink conjunctiva, no discharges, anicteric sclera

Ears: symmetrical, no discharges, no malformation

Nose: no watery discharges, no nasal flaring

Mouth: moist, no hypersalivation, no cleft/lip palate

Neck: no webbing

Chest and lungs: Symmetrical chest expansion, no retractions, clear breath sound, no grunting

Heart: adynamic precordium, PMI at 4th ICS midclavicular line, normal rate, regular rhythm, no murmur

Abdomen: Globular, soft, no organomegaly, no abdominal distension

Genitalia and anus: Grossly male, no discharge

Extremities: No gross deformities, no edema, no clubbing, pinkish nail beds CRT 2 seconds, full and equal
pulses