PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: January 5, 2021

Vital Signs:
Temp: _37.5°C___ RR: __21 cpm_____ Weight: _____54 kg_________
PR: _110bpm___ BP: _140/60 mmHg_ Height: _______5” 4’_______

Observation: _Headache, lightheadedness or dizziness, difficulty breathing, and palpitations______________________________________________________________

1. General (weight loss or Client is alert and cooperative. Speech is clear, without slur or stutter. Expresses ideas and feelings clearly and concisely. Makes and maintains eye contact
gain; fever, chills, night during conversation. Follows verbal cues and is dressed appropriately.
sweats; mood; stage of
development, race, sex;
signs of distress; position;
cooperative or not; state if
irritable, agitated or
pleasant; etc.)
2. Head (headache, injury, Head- Head is symmetrically round, hard and smooth, without lesions or bumps. Full and controlled ROM of the neck.
tenderness, etc.); Eyes
(change in visual fields, Eyes- Eyes are symmetrical with no redness and discharges. Conjunctiva and sclera moist and smooth with no lesions noted. Iris uniformly dark brown.
glasses, blurring, diplopia,
pain, loss of vision, tearing, Ears- Bilateral auricles without deformity, lumps or lesions
dry eyes, etc.); Ears
(change in hearing, tinnitus, Nose -Nasal septum midline without bleeding, perforation or deviation. Nares patent.
discharge, dizziness, etc.);
Nose (allergies, sinus Throat- Lips are pink and smooth with no lesions and ulcerations. Tongue is midline mid line when protruded, no lesions or masses. No ulcers or nodules.
problem, obstruction,
polyps, sneezing, epistaxis,
etc.);Throat (toothaches,
loose teeth, bleeding gums,
mouth sores, hoarseness,
difficulty swallowing, etc.)

3. Integumentary System Skin is dark brown, warm and dry to touch. No excoriations. Hair is black and straight with scattered grey streaks. No scalp lesions or flaking. Fingernails are
clean with immediate capillary refill (<2 seconds). No clubbing or Beau lines. No Edema.

4. Respiratory System Respirations are even, unlabored and regular. No use of accessory muscles and no nasal flaring.
(chest pain, dyspnea,

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cough, amount and color of
sputum, hemoptysis, etc.)

5.Cardiovascular System Patient reports palpitations and shortness of breath related to hypertension. Denies any chest pain and tightness.
(chest pain/ pressure/
tightness, palpitations,
orthopnea, paroxysmal
nocturnal dyspnea,
shortness of breath,
edema, claudication,
endurance, etc.)
6. Digestive System Abdomen is rounded and symmetric, without masses, lesions, pulsations or peristaltic waves. Umbilicus in midline, without herniation, swelling and
(dysphagia, heartburn, discoloration.
ulcer, GERD, indigestion,
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 Patient’s urine is light yellow and reports no pain upon urination and no urinary incontinence.
(urgency, frequency,
nocturia, dysuria,
hematuria, recurrent UTIs,
STD, incontinence, etc.)
8.Musculoskeletal System Posture is erect. Gait steady, smooth and coordinated. Upper and lower extremities are symmetric, without lesions, nodules and deformities, or swelling.
(limitation in movement, Muscle tone intact with no atrophy, tremors or weakness. Patient reports occasional acute pain in joints.
stiffness, joint pain, swelling
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. Oriented to person and place but has difficulty
recalling date and events. Remains attentive and able to focus on examination during interaction.

10. Endocrine System No reported intolerance to heat/cold and no changes in hair distribution. Patient reports fatigue related to hypertension.
(heat/cold intolerance,
weight change, fatigue,
polydipsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
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11. Reproductive System No reported unusual discharges or lesions.

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