PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: ______________

Vital Signs:
Temp: 37.9 ºC RR: 22 cpm Weight: ______________
PR: 100 bpm BP: 90/60 Height: ______________

Observation: _______________________________________________________________________________________

1. General (weight loss or

gain; fever, chills, night Patient is weak looking, conscious, and coherent and has difficulty sleeping on flat bed. (di ko sure if ang sleeping kay diri mo sulod). Patient also prefers
sweats; mood; stage of darkened room and is easily irritated, and nauseated.
development, race, sex;
signs of distress; position;
cooperative or not; state if
irritable, agitated or
pleasant; etc.)

2. Head (headache, injury,

tenderness, etc.); Eyes (+) dry lips, NAD (Nothing abnormal is detected). Patient complaints of headache.
(change in visual fields, (+) eye sensitivity to light
glasses, 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, hoarseness,
difficulty swallowing, etc.)
3. Integumentary System
(-) jaundice, (-) pallor, (-) cyanosis, no active dermatoses

4. Respiratory System Respiratory rate is 26/min, regular, shallow and breathes through the nose mouth.
(chest pain, dyspnea, SCE, (-) retractions, (-) crackles, no wheezes noted.  AP: no murmur.  
cough, amount and color of
sputum, hemoptysis, etc.)

Patient’s Name / Room No. | 1

5.Cardiovascular System
(chest pain/ pressure/ Normal Rate Regular Rhythm, (-) murmurs.
tightness, palpitations,
orthopnea, paroxysmal
nocturnal dyspnea,
shorntness of breath,
edema, claudication,
endurance, etc.)
6. Digestive System (-) BM from admission to present, no mass palpated, no tenderness. GUT: Unremarkable.
(dysphagia, heartburn,
ulcer, GERD, indigestion, (+) nausea, vomiting, and lack of appetite
food intolerance, diarrhea,
constipation, abdominal
pain, 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 UTIs,
STD, incontinence, etc.)
8.Musculoskeletal System
(limitation in movement,
stiffness, joint pain, swelling
or redness, arthritis, muscle
spasms, muscle weakness,
etc.)
9. Nervous System
Neuro: (+) neck rigidity, (+) brudzinki’s sign, (+) kernig’s sign, (-) babinski reflex, lethargy, and irritability

10. Endocrine System

(heat/cold intolerance,
weight change, fatigue,
polydepsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
11. Reproductive System

Patient’s Name / Room No. | 2

I BLUE NAKO ANG KULANG NA CLINICAL MANIFESTATIONS NA AKONG NA SEARCH HA PARA LANG MA DIFFERENTIATE, THOUGH ANG UBAN DATA KAY NAA SA CASE

 Fever
 Headache
 Stiff neck
 Eyes being more sensitive to light
 Sleepiness or trouble waking up from sleepß
 Nausea
 Irritability
 Vomiting
 Lack of appetite
 Lethargy (a lack of energy)

Patient’s Name / Room No. | 3