PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: April 26, 2021

Vital Signs:
Temp: 36.1˚C RR: 18 cpm Weight: 63 kg
PR: 88 bpm BP: 120/80 mmHg Height: 5’4’’

Observation: Pt is awake, conscious, oriented to time, person and place and responsive.

1. General (weight loss or

gain; fever, chills, night
sweats; mood; stage of Pt is a 46 year old male, received while lying in bed, conscious, coherent, responsive, and well-groomed;
development, race, sex; signs No signs of distress and agitation. Patient was cooperative during the interview and physical assessment;
of distress; position; Patient’s pain score: 8/10; (-) Fever [Temp: 36.1˚C]; Pt appears appropriate to age; Normal BMI.
cooperative or not; state if
irritable, agitated or pleasant;
etc.)
2. Head (headache, injury, Head: Patient’s head is normocephalic, non-tender; No visible or palpable masses, depressions, or scarring;
tenderness, etc.); Eyes Hair is of normal texture and evenly distributed; no complaints of headache.
(change in visual fields,
glasses, blurring, diplopia,
Eyes: PERRLA [pupils equal, round, and reactive to light and accommodation]; Pt uses corrective glasses
pain, loss of vision, tearing,
dry eyes, etc.); Ears (change when reading.
in hearing, tinnitus, discharge,
dizziness, etc.); Nose Ears: Ears are symmetrical; The auricles are in proper alignment, symmetrical and have the same color
(allergies, sinus problem, as the facial skin; (-) deformities of the ears; (-) hearing disabilities.
obstruction, polyps, sneezing,
epistaxis, etc.);Throat Nose: Nose is symmetric, in the midline, and in proportional to other facial features.
(toothaches, loose teeth,
bleeding gums, mouth sores,
hoarseness, difficulty Throat: No swallowing difficulty reported. Oral mucosa is pink and moist. Tongue normal in appearance without
swallowing, etc.) lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in
appearance without tonsillar swelling or exudates.

3. Integumentary System
(+) Presence of abrasions on right arm; untrimmed nails on both hands; Abrasions noted on both upper extremities;
Hair is evenly distributed.

4. Respiratory System
(chest pain, dyspnea, cough,
amount and color of sputum, RR: 18 cpm; O2 Saturation: 98%; No reported chest pain and cough; no signs of patient having difficulty breathing.
hemoptysis, etc.)

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5.Cardiovascular System
(chest pain/ pressure/
tightness, palpitations, HR: 88 bpm; BP: 120/80 mmHg; CRT: <2 sec; Heart rate and rhythm are normal. No murmurs, gallops, or rubs
orthopnea, paroxysmal are auscultated. S1 and S2 are heard and are of normal intensity.
nocturnal dyspnea, shorntness
of breath, edema,
claudication, endurance, etc.)
6. Digestive System
(dysphagia, heartburn, ulcer,
GERD, indigestion, food
intolerance, diarrhea, (-) Bowel movement from admission to present; hypoactive bowel sounds; (-) Dysphagia;
constipation, abdominal pain, No data on the patient’s stool [pt has not yet defecated].
blood in stool, black tarry
stools, changes in bowel
habits, reduced caliber of
stools, hemorrhoids, etc.)
7. Excretory System
(urgency, frequency, nocturia,
dysuria, hematuria, recurrent Pt has urinated 420 mL; negative for dysuria, nocturia, hematuria.
UTIs, STD, incontinence, etc.)

8.Musculoskeletal System
(limitation in movement, 13 kg skeletal traction on right leg; Pt reports of slight muscle weakness on both legs; muscle grade strength of
stiffness, joint pain, swelling or
1/5 on right lower extremities, 4/5 at left lower extremities, 5/5 both upper extremities; Limited ROM in affected area.
redness, arthritis, muscle
spasms, muscle weakness,
etc.)
9. Nervous System
Pt is conscious, coherent, responsive, and oriented to time, person, and place; Memory is normal and thought
process is intact. Pt experiences interrupted sleep due to pain from the fracture site; Pain score: 8/10.

10. Endocrine System

(heat/cold intolerance, weight
change, fatigue, polydepsia, No heat or cold intolerance reported and hair is evenly distributed throughout the body.
polyuria, polyphagia, changes
in hair distribution, etc.)
11. Reproductive System
Pt is male and appears appropriate for age; Pt was circumcised at age 10.
No remarkable findings [No abnormalities found upon assessment].