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Review of Systems

GENERAL HEALTH Momay is 21 years old female, who articulates clearly, ambulates without difficulty and in good proper grooming. Awake, coherent, afebrile, no fatigue but slightly weak and tired, comfortable and not in any form of respiratory distress. SKIN Uniform skin color with slightly darker in exposed areas. No unusual odor. No skin lesion no vascular lesion noted. Warm to touch with good skin turgor. With bruise on both hands, about 3cm in diameter in left hand and 2cm in diameter in right hand. Hair, normal distribution and texture, no pest inhibitants. Nail beds pinkish and with prompt capillary refill time < 3 seconds. Fine body hair noted over the body. Generalized edema noted. HEAD Normocephalic, Relatively smooth with no unexpected contours or bulges. With normal hair distribution. No lumps, scaling, parasites. Scalp intact and free lesions, pediculosis, mobile and nontender. Face symmetric, no involuntary movement. EYES Visual field full by confrontation. EOM intact. Eyes clear and bright. Present and curving outward of eyelashes noted. Periorbital edema noted. palpebral fissures symmetrical. Eyelids in contact with eyeball. No lesions. No swelling, redness, or drainage of Lacrimal gland and Nasolacrimal Duct. Palpebral conjunctiva is smooth glistening, pinkish-peach color, with minimal blood vessels visible. Sclera white, no lesion or redness. PERRLA, pupils size of 5cm. EARS Helix of ear is level with imaginary line drawn through inner and outer canthus to occiput. Intact, no lesions noted. Consistent with skin color. Cerumen is the only normal drainage. Soft and pliable, nontender. No foreign objects. Canal patent. Free of redness and drainage. No hearing loss or difficulty. NOSE Midline placement. Shape is symmetrical and consistent. No nasal flaring, no drainage. No sinus pain, nasal obstruction. Cartilaginous portion is slightly mobile. Nontender, no masses. Nares patent. No epistaxis or allergy noted. MOUTH AND THROUT Mucosa and gingivae pink, no lesions and bleeding. Tongue symmetric, protrudes midline, no tremor. Gag reflex present. NECK

Neck erect, midline, no lumps, bulges, or masses. Thyroid not visible. No masses, swelling, or hypertrophy in mid to lower half of anterior neck. No neck pain and limitation of motion. RESPIRATORY Anterior, posterior and lateral chest skin is intact and chest expansion equal. Trachea is midline. Chest is nontender, no deformities or crepitus. Symmetrical without lag. Normal causes of decreased excursion are habitual shallow breathing or wearing tight, restrictive undergarments. Equal bilaterally and diminished midthorax. Resonance to second intercostal space on left; slight dullness over third through fifth intercostal space over heart. Resonance to fourth intercostals space on right with dullness from approximately fifth to just above costal margin over liver. Resonance noted upon pecussing the Lateral and Posterior thorax. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes, or rubs. No past history of lungs disease, no chest pain, With respiratory rate of 26 cpm. CARDIOVASCULAR SYSTEM Positive carotid and apex pulsation. Negative thrills upon palpating precordium. Dullness at third, fourth and fifth intercostal spaces to left of sternum at midclavicular line. Negative bruits and venous bum. No aortic murmurs. No chest pain, non palpable, no cyanosis but slight edema noted. With anemia and hypertension history. PERIPHERAL-VASCULAR ANG LYMPHATIC SYSTEM Skin color uniform. Edema noted. No lesions. No pain. No coldness, No varicosities or only superficial ones. No swelling but pitting edema noted on right pedal grade 1, and nonpitting edema on left pedal. Cervical nodes are nonpapable. Brachial, radial, ulnar, popliteal, posterior tibial, and dorsalis pedis pulses are easily palpated. no vascular sounds heard on auscultation. GASTROINTESTINAL SYSTEM With good appetite with no recent change. No food intolerance, indigestion, heartburn, pain in abdomen, nausea or vomiting. No history of ulcer, liver and gall bladder disease. On low salt, low fat diet. s ELIMINATION Bowel movement x2 a day, soft brown, no rectal bleeding. GENITOURINARY SYSTEM Menarche at age 12. irregular menstruation, duration of 4-5days, moderate flow, seldom dysmenorrhoeal. No vaginal itching. NEUROLOGIC SYSTEM Patient is able to identify substance. Patient experiencing headache sometimes.

ACTIVITIES OF DAILY LIVING Independent, and can perform the task as well as peers do, or with minor difficulty only. SLEEP Patient can sleep at long interval. 4 hours in the morning. 6-7 in the evening, PRESENT BEHAVIOR Awake, coherent, afebrile, no fatigue but slightly weak and tired, in good proper grooming. Not in any form of respiratory system. ENVIRONTMENT Well ventilated conducive for resting. SOCIO-ECONOMICS STATUS