PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: __April 29-31______

Vital Signs:
Temp: __36.3 C_____ RR: __20 cpm_____ Weight: _60kg__
PR: __80 bpm_____ BP: _110/80 mmHg__ Height: _______

Observation: _______________________________________________________________________________________

1. General (weight Patient didn’t experience any changes of weight. Doesn’t have fever nor chills. Night sweats not evident. Patient is lying on bed, in a
loss or gain; fever, supine position, conscious, coherent, responsive but lethargic, no signs of distress and poorly groomed. He was cooperative during
chills, night sweats; the interview and physical assessment. Patient is awake, conscious, coherent and responsive, oriented to time, person and place.
mood; stage of
development, race,
sex; signs of distress;
position; cooperative or
not; state if irritable,
agitated or pleasant;
etc.)
2. Head (headache, Patient’s head is normocephalic, with hair evenly distributed. Patient has no tenderness upon palpation. PERRLA. (+) Peri-orbital
injury, tenderness, hematoma noted on both eyes with sub-conjunctiva hemorrhage on left eye due to alleged mauling. Ears are symmetrical, no
etc.); Eyes (change in tinnitus and no discharges upon inspection. Patient has no known nose allergies, sinus problems, obstructions, nor polyps. (-)
visual fields, glasses, epistaxis. (-) dysphagia, no hoarseness of voice, no loose teeth, and no mouth sores.
blurring, diplopia, pain,
loss of vision, tearing,
dry eyes, etc.); Ears
(change in hearing,
tinnitus, discharge,
dizziness, etc.); Nose
(allergies, sinus
problem, obstruction,
polyps, sneezing,
epistaxis, etc.);Throat
(toothaches, loose
teeth, bleeding gums,
mouth sores,
Patient’s Name / Room No. | 1
hoarseness, difficulty
swallowing, etc.)
3. Integumentary Presence of wound scars on right arm; nails on both hands are not trim.
System

4. Respiratory (-) DOB/SOB. No chest pain. Chest I:E= 1:2,rr ranges from 12-15cpm. No coughs.
System
(chest pain, dyspnea,
cough, amount and
color of sputum,
hemoptysis, etc.)

5.Cardiovascular CRT < 3 seconds, HR ranges from 70-80cpm. (-) DOB/SOB.

System (chest pain/
pressure/ tightness,
palpitations,
orthopnea, paroxysmal
nocturnal dyspnea,
shortness of breath,
edema, claudication,
endurance, etc.)
6. Digestive System (-) Dysphagia. No heart burns, GERD, ulcers, indigestions, and diarrhea. Defecated once with brownish semi formed stool, (+)
(dysphagia, heartburn, borborygmi (+) healed incision was noted on the right iliac border of the abdomen
ulcer, GERD,
indigestion, food
intolerance, diarrhea,
constipation,
abdominal pain, blood
in stool, black tarry
stools, changes in
bowel habits, reduced
caliber of stools,
hemorrhoids, etc.)

Patient’s Name / Room No. | 2

7. Excretory System Urine output approximately 320ml for 8 hrs. No burning upon urination, no hematuria, no known UTIs and STDs.
(urgency, frequency,
nocturia, dysuria,
hematuria, recurrent
UTIs, STD,
incontinence, etc.)
8.Musculoskeletal (+)Swelling noted on right knee and thigh; pain was reported by the patient with a pain scale of 8/10. Intramedullary bone pins are
System (limitation in transversely inserted on proximal 3rd right tibia with 10 kg skeletal traction in place. Muscle grade strength ⅗ at R leg, ⅘ @ L leg,
movement, stiffness, 5/5 on both upper extremities.
joint pain, swelling or
redness, arthritis,
muscle spasms,
muscle weakness,
etc.)
9. Nervous System Patient is awake, conscious, coherent and responsive, oriented to time, person and place.

10. Endocrine Patient has (-) heat/cold intolerance and no weight changes. No polyuria, polydipsia, and polyphagia noted.
System
(heat/cold intolerance,
weight change, fatigue,
polydipsia, polyuria,
polyphagia, changes in
hair distribution, etc.)
11. Reproductive Patient is male, circumcised at age 10.
System

Patient’s Name / Room No. | 3