PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: March 29-31, 2021

Vital Signs:
Temp: 36.3 o C RR: 20 cpm Weight: 60kg
PR: 80 bpm BP: 110/80 mmHg Height: N.I.

Observation: During assessment pt is awake, conscious, and coherent. He is responsive but lethargic. Pt reported pain w/ a scale of 8/10. No signs of distress noted.

1. General (weight loss or

gain; fever, chills, night Pt has a weight of 60 kg. Vital signs as follows PR: 80 bpm, RR: 20 cpm, BP: 110/80 mmHg, O2 Saturation: 97%. The pt is afebrile as evidenced by a temperature
sweats; mood; stage of of 36.3 o C. Patient is a 44-year-old male married Filipino and is currently unemployed. Upon assessment patient is awake, conscious, and coherent. He is
development, race, sex; oriented to time, person and place. He is responsive but lethargic. There are no signs of distress noted. The pt is poorly groomed. Pain was reported by the
signs of distress; position; patient with a pain scale of 8/10. The patient is cooperative during interview. Speech is clear without slur or stutter. Expresses ideas and feelings clearly and
cooperative or not; state if concisely. Makes and maintains eye contact and conversation. Follows verbal cues.
irritable, agitated or
pleasant; etc.)
2. Head (headache, injury,
tenderness, etc.); Eyes Head is normocephalic, symmetrical, round, hard and smooth, without lesions or bumps. Pupil is equal, round, and reactive to light and accommodation. (+)
(change in visual fields, Periorbital hematoma noted on both eyes with subconjunctival hemorrhage on left eye due to alleged mauling. Ears are symmetrical. Bilateral auricles without
glasses, blurring, diplopia, deformity, lumps, or lesions. Mastoid processes nontender. Lips is pink, smooth, and moist; no lesions or ulcerations. Buccal mucosa pink and moist. No ulcers
pain, loss of vision, tearing, and nodules. Gums are pink and moist, without inflammation, bleeding or discoloration. Hard and soft palates smooth, without lesions or masses. Tonsils present,
dry eyes, etc.); Ears without exudate, edema, ulcers or enlargement. Pt’s nose external structure without deformity, asymmetry, or inflammation. Nares patent. Turbinates and middle
(change in hearing, tinnitus, meatus pale pink, without swelling, exudate, lesions, or bleeding. Nasal septum midline without bleeding, perforation, or deviation. Frontal and maxillary sinuses
discharge, dizziness, etc.); nontender. (-) Dysphagia.
Nose (allergies, sinus
problem, obstruction,
polyps, sneezing, epistaxis,
etc.);Throat (toothaches,
loose teeth, bleeding gums,
mouth sores, hoarseness,
difficulty swallowing, etc.)
3. Integumentary System
Hair is evenly distributed. No scalp lesions or flaking. Presence of wound scars on right arm; nails on both hands are not trim. (+)Swelling noted on right knee
and thigh.

4. Respiratory System
(chest pain, dyspnea, O2 Saturation: 97%. (-) DOB/SOB. Chest I:E= 1:2. RR ranges from 12-15cpm. Respirations are even, unlabored, and regular. No use of accessory muscles
cough, amount and color of and no nasal flaring. Thorax expands symmetrically without retractions or bulging. Percussion resonant throughout. Vesicular breath sounds heard in all lung
sputum, hemoptysis, etc.) fields. No adventitious sounds. No whispered pectoriloquy, bronchophony, or egophony noted.

Patient’s Name / Room No. | 1

5.Cardiovascular System
(chest pain/ pressure/ CRT < 3 seconds, HR ranges from 70-80cpm. Pt’s heart rate and rhythm are regular. No S3 and S4. No murmurs, gallops, rubs, splitting, clicks, or snaps. No
tightness, palpitations, carotid bruits or jugular vein distention. No precordial pulsations, heaves, lifts or vibrations visible.
orthopnea, paroxysmal
nocturnal dyspnea,
shorntness of breath,
edema, claudication,
endurance, etc.)
6. Digestive System
(dysphagia, heartburn, Defecated once with brownish semi formed stool, (+) borborygmi, urinary output approx. 320ml for 8 hrs. (+) healed incision was noted on the right iliac border
ulcer, GERD, indigestion, of the abdomen. Denies mucoid stools, melena, or hematochezia. No reports of rectal bleeding, change in color, consistency, or habits noted.
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, No reports of dysuria, hematuria, polyuria, hesitancy, incontinence, or nocturia.
nocturia, dysuria,
hematuria, recurrent UTIs,
STD, incontinence, etc.)
8.Musculoskeletal System
(limitation in movement, Intramedullary bone pins are transversely inserted on proximal 3rd right tibia with 10 kgs skeletal traction in place. Muscle grade strength ⅗ (active movement
stiffness, joint pain, swelling against gravity) at R leg, ⅘ at L leg (active movement against gravity and some resistance), 5/5 on both upper extremities.
or redness, arthritis, muscle
spasms, muscle weakness,
etc.)
9. Nervous System
Facial expressions symmetric and correlate with mood and topic discussed. Speech is clear and appropriate. Follows through with train of thought. Carefully
chooses words to convey feelings and ideas. Oriented to person, place, time, and events. Remains attentive and able to focus on examination during
interaction. Short- and long-term memories intact. Vocabulary suitable to educational level.

10. Endocrine System

(heat/cold intolerance, Pt’s hair is evenly distributed. (-) heat/cold intolerance. No weight change noted. No fatigue, polydipsia, polyuria, polyphagia was reported. There are no signs
weight change, fatigue, and symptoms present indicating abnormal breast and regional lymphatics.
polydepsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
11. Reproductive System
Pt. is male, circumcised at age 10. No abnormal findings were reported.

Patient’s Name / Room No. | 2