FAMILY DYNAMICS

ANAMNESIS
 REVIEW OF SYSTEMS
COVID-19 Screening In the past 2 weeks, the patient did not have cough, fever, fatigue, anosmia, ageusia. He was not exposed to a suspected nor
confirmed case of COVID-19.

Constitutional No weight loss. No fever. No night sweats. No chills. No fatigue. No anorexia.

Skin No skin lesions. No pruritus. No nipple discharges.
Neurologic No weakness. No paresthesia. No numbness. No loss of consciousness. No dizziness. No recent falls. No headache.

Head, Eyes, Ears, Nose, and No blurring of vision. No eye pain. No infraorbital ecchymosis. No foreign body sensation. No discharge. No hearing changes. No ear
Throat pain. No nasal congestion. No hoarseness of voice. No sore throat. No rhinorrhea. No dysphagia.

Cardiovascular No palpitations. No chest discomfort. No chest pain. No dyspnea on exertion. No dysphagia.

Respiratory No cough. No shortness of breath.
Gastrointestinal No abdominal pain or tenderness. No vomiting. No nausea. No diarrhea. No constipation. No melena. No hematochezia.

Genitourinary No urinary incontinence. No dysuria. No urinary frequency. No hematuria. No flank pain.

Musculoskeletal No myalgias. No joint swelling. No joint stiffness.
Endocrine No polydipsia. No polyuria. No polyphagia. No temperature intolerance.
Hematologic No bruising. No bleeding. No history of transfusions. No lymphadenopathy.
Psychiatric No anxiety symptoms. No obsessive-compulsive symptoms were noted.
 PHYSICAL EXAMINATION
General Data:
•Patient was seen with clean and appropriate clothing
with unusual head accessory and unusual necklace.

Vital Signs: Skin Fair complexion. Good skin turgor. No lesions noted. No cyanosis. No pallor. No jaundice.
HEENT Normocephalic. Anicteric sclerae. Pink palpebral conjunctivae. Moist lips and tongue. No nasal
BP: LR: 17 Weight: BMI: discharges. No nasal discharges. no tonsillar redness or enlargement.
110/70 cpm 72.7 kg 22.7 Neck No cervicolymphadenopathies. No tenderness.
mmHg kg/m2 - Chest and Lungs Equal chest expansion. Clear breath sounds. No deformities.
Normal Heart Adynamic precordium. With regular rate and rhythm. No murmur.
CP: 89 Temp: Height: Abdomen Flat. Normoactive bowel sounds. Non tender.
bpm 36.9°C 179 cm Extremities No gross deformities. CRT <2 seconds. Strong pulses.
Cranial Nerves Examination
CN I Able to smell coffee.
CN II Pupils are reactive to light and accommodation.
CN III, IV, VI Full extraocular movements.
CN V Positive corneal reflex, able to open and close mouth with ease.
CN VII Able to smile, frown, raise both eyebrows, show teeth symmetrically.
CN VIII Able to hear via whisper test.
CN IX, X Able to swallow.
CN XI Able to shrug shoulders. Able to turn head from side to side.
CN XII Tongue in midline and symmetrical.
Sensory and Intact light touch and pinprick sensation. Motor strength 5/5 on all extremities.
Motor
Cerebellar Negative for dysdiadochokinesia and nystagmus.
Examination Negative for Romberg’s test.
Normal gait.
Babinski Negative
Meningeal Signs Negative for Brudzinski and Kernig sign. No nuchal rigidity.