REVIEW OF SYSTEMS FOR CURRENT HEALTH PROBLEMS

Skin, hair, and nails: color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff

Patient SO reports having brown skin color, equally warm temperature in both upper and lower parts of the
body, with no rashes, lesions, excessive sweating, hair loss, dandruff in the patient.

Head and neck: headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat

Patient SO report that the patient experienced headache, with no stiffness, difficulty swallowing, sore throat,
however SO reports palpable lymph nodes on the right side of the neck.

Ears: pain, ringing, buzzing, drainage, difficulty hearing, exposure to loud noises, dizziness, drainage

Patient SO reports that the patient doesn’t experience pain ringing, buzzing, drainage, difficulty hearing,
exposed to loud noises, dizziness.

Eyes: pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double
vision

Patient SO reports that the patient doesn’t experience pain, infection impaired vision, redness, halos, blurring,
black spots, flashes, double vision. However patient SO reports “muta lang akong mapansin sa iyaha”.

Mouth, throat, nose, and sinuses: mouth pain, sore throat, lesions, hoarseness, nasal obstruction,
sneezing, coughing, snoring, nosebleeds

Patient SO reports that the patient doesn’t experience mouth pain, sore throat, lesions, hoarseness, nasal
obstruction, sneezing, coughing, snoring, nosebleeds.

Thorax and lungs: pain, difficulty breathing, shortness of breath with activities, orthopnea, cough,
sputum, hemoptysis, respiratory infections.

Patient SO reports that the patient doesn’t experience pain, difficulty breathing, shortness of breathing with
activities, orthopnea, cough, sputum, hemoptysis, respiratory infections.

Breasts and regional lymphatics: pain, lumps, discharge from nipples, dimpling or changes in breast size,
swollen and tender lymph nodes in axilla

Patient SO reports that the patient doesn’t experience pain, lumps, swollen and tender lymph nodes in axilla.

Heart and neck vessels: chest pain or pressure, palpitations, edema, last blood pressure, last ECG

Patient SO reports that the patient doesn’t experience chest pain or pressure, palpitations, edema.

Peripheral vascular: leg or feet pain, swelling of feet or legs, sores on feet or legs, color of feet and legs

Patient SO reports that the patient doesn’t experience leg or feet pain, swelling of feet or legs, sores on feet or
legs. However, patient SO reports that the lower extremities is warmer than the upper.

Abdomen: pain, indigestion, difficulty swallowing, nausea and vomiting. Gas, jaundice, hernias

Patient SO reports that the patient experienced pain, nausea, and vomiting.

Male genitalia: painful urination, frequency or difficulty starting or maintaining urinary system, blood in
urine, sexual problems, penile lesions, penile pain, scrotal swelling, difficulty with erection or
ejaculation, exposure to STIs

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Patient SO reports that the patient doesn’t experience painful urinating, no blood in urine, penile lesions, penile
pain, scrotal swelling.

Anus, rectum, and prostate: pain, with defecation, hemorrhoids, bowel habits, constipation, diarrhea,
blood in stool

Patient SO reports that the patient doesn’t experience pain with defecation, hemorrhoids, diarrhea, and blood in
stool.

Musculoskeletal: pain, swelling, redness, stiff joints, strength of extremities, abilities to care for self and
work

Patient SO reports that the patient experienced tiredness, decrease spontaneous activity due to weakness.

Neurologic: mood, behavior, depression, anger, headaches, concussions, loss of strength or sensation,
coordination, difficulty with speech, memory problems, strange thoughts or actions, difficulty reading
or learning

Patient SO reports that the patient is irritable with unfamiliar staffs or being fearful. However, patient SO
reports that the patient is cooperative and warm ups easily as time passed.

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Physical Examination (See Appendix B Physical Assessment Guide Pp. 889-893)

Physical Assessment Area Normal findings Abnormal Findings

Vital signs: T - 36.7°C O2Sat - 96% PR - 104 BPM RR - 37cpm
Height: 96cm ( 38 inches )
Weight: 15kg
BMI: 16.1

Mental Status and Substance Abuse

Observe LOC, posture and body Patient is awake with appropriate Weakness noted
movements, facial expressions, speech, response to verbal stimuli. Posture
mood, feelings, and expressions, though is relaxed, minimal spontaneous
process and perceptions movement observed. Facial
expression shows tiredness and
occasional discomfort. Speech is
clear and aged - appropriate.
Initially anxious around unfamiliar
staff but becomes cooperative with
reassurance. Display appropriate
emotional expression and
understanding of the routine
procedures. No signs of altered
perception or disorganized though
process.

Assess cognitive abilities Patient is awake, responds Weakness noted

appropriately to verbal stimuli.
Recognizes familiar faces and
cooperate during procedures by
anticipating actions. Understand
simple instructions, speaks in short
phrases, and shows age-appropriate
memory and focus. Initially shy
around many people but warms up.

General Appearance: Patient is lying in bed, appears Appears weak, low overall
responsive, maintain eye contact activity level noted.
when addressed, fearful or
unfamiliar staffs, but cooperative
once engaged, demonstrate
awareness of procedures. Well-
groomed and dressed appropriately.

Skin and nails The skin is warm to touch and no Noticeably increased
sweating. Skin is tan in color with warmth in the lower
no bruises. Nails are clean and well extremities compared to the
trimmed. No signs of biting or upper. Delayed capillary
damaged. Nail beds are pink. refill of 5 seconds. Notices
rashes in his left legs.
Hair Hair is evenly distributed, soft and Oily and unpleasant odor is
clean. No lice, flaking, or bald noted.
areas.

Head Head shape looks even on all sides. No concern noticed.

No wounds, lumps, or soft spots
felt. Scalp is clean and free from
redness or flaking.

Eyes Both eyes are of the same size and Eye discharge was noticed
shape. The child follows movement but immediately wiped off
and pupil reacts to light by the mother with face
accomodations. Sclera is white. The towel.
eyelids open well and no redness
noticed. Eyelashes are evenly
distributed, 3

Ears Ears are clean, no foul smell, and No concern noticed.

same level on both sides of the