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    Review of Systems

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    Liza Marie Cayetano Adarne
    The document provides a review of systems for a patient during admission and present assessment. It examines multiple body systems and notes current symptoms and examination findings. For general, the patient has right-sided weakness. Neurologically, the patient is lethargic with a GCS of 10 and shows signs of right hemiplegia including 1/5 strength on the right side and inability to feel light touch on the right. The patient also has constipation.

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    Review of Systems

    Uploaded by

    Liza Marie Cayetano Adarne
    111 views3 pages
    The document provides a review of systems for a patient during admission and present assessment. It examines multiple body systems and notes current symptoms and examination findings. For general, the patient has right-sided weakness. Neurologically, the patient is lethargic with a GCS of 10 and shows signs of right hemiplegia including 1/5 strength on the right side and inability to feel light touch on the right. The patient also has constipation.

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    The document provides a review of systems for a patient during admission and present assessment. It examines multiple body systems and notes current symptoms and examination findings. For general, the patient has right-sided weakness. Neurologically, the patient is lethargic with a GCS of 10 and shows signs of right hemiplegia including 1/5 strength on the right side and inability to feel light touch on the right. The patient also has constipation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    111 views3 pages

    Review of Systems

    Uploaded by

    Liza Marie Cayetano Adarne
    The document provides a review of systems for a patient during admission and present assessment. It examines multiple body systems and notes current symptoms and examination findings. For general, the patient has right-sided weakness. Neurologically, the patient is lethargic with a GCS of 10 and shows signs of right hemiplegia including 1/5 strength on the right side and inability to feel light touch on the right. The patient also has constipation.

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    At a glance
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    The patient presents with right-sided weakness and is lethargic. Physical examination reveals pallor, scars, and bed sores. Neurological examination shows right-sided facial palsy and weakness.

    Physical examination reveals pallor on the lower extremities, presence of bed sores and blisters on the feet, limitation of motion of the neck to the right side, and rhonchi on lung auscultation.

    Neurological examination reveals right-sided central facial palsy, tongue protrusion to the right, difficulty turning the head to the right, 1/5 strength in the right upper and lower extremities, absent sensation to light touch in the right upper and lower extremities, and a positive Babinski reflex on the right.

    REVIEW OF SYSTEMS

    DURING ADMISSION PRESENT ASSESMENT


    GENERAL
    no weight loss, no fever, no
    chills

    current weight unidentified,
    no fever, no chills, lethargic,
    with right-sided weakness
    (hemiplegic)
    weight change/fever/sweats/anorexia/
    weakness/fatigue/insomnia/others
    SKIN
    no rashes, no pallor, no
    jaundice, no easy
    bruisability

    with scars on lower
    extremities, with pallor on
    lower extremities, cold and
    clammy skin, poor capillary
    reflex, white hair (equally
    distributed), presence of
    bed sores in the gluteal area
    (grade 2), presence of
    blisters in the feet,
    desquamation in the
    inguinal area, clean and
    short nails
    itchiness/color change/
    pigmentation/rash/
    vasomotor change/
    photo-sensitivity/hair/nails/
    moles/others
    EYE
    no eye discharge, no
    pruritus, no pain



    visual dysfunction/redness/
    itchiness/pain/
    scotomata/lacrimation/others
    EAR
    no tragal tenderness, no
    tinnitus, no aural discharge

    no deafness, no tragal
    tenderness, no tinnitus, no
    aural discharge
    deafness/tinnitus/discharge/others
    NOSE
    no colds, no epistaxis, no
    nasal discharge

    no colds, no epistaxis, no
    nasal discharge, with NGT
    on left naris
    epistaxis/discharge/
    obstruction/smell post-op drip/
    sinusitis/others
    MOUTH
    bleeding gums/sores/fissures/
    tongue abnormalities/dental caries/others
    no toothache, no bleeding
    gums, no sores, no fissures
    no bleeding gums, no sores,
    no fissures, with oral white
    secretions (saliva), with
    loose tooth on upper left,
    have difficulty moving his
    tongue, cant eat thru
    mouth
    THROAT
    no tonsillitis, no toothaches,
    no gum bleeding, no mouth
    sores, no sore throat, no
    hoarseness, no dysphagia

    no tonsillitis, no gum
    bleeding, no mouth sores,
    no sore throat, murmuring
    of words, cant eat (with
    NGT on left naris)
    soreness/tonsillitis/others
    NECK
    stiffness/limitation of motion/
    masses adenopathy/sensation/
    of lump in the throat/ others
    no stiffness, no dysphagia with limitation of motion,
    had difficulty turning into
    his neck into his right side
    PULMONARY
    no cough, no sputum, no
    dyspnea, no hemoptysis

    no cough, no hemoptysis,
    with difficulty of breathing,
    (+) rhonchi, bilateral
    dyspnea/shortness of
    breath/cough/sputum/
    hemoptysis/wheezing/back pain/
    chest wall abnormality/others
    CARDIAC
    no chest pain, no
    palpitations, no paroxysmal
    dyspnea (PND), no
    orthopnea, no easy
    fatigability, no syncope

    no chest pain, no
    palpitation, no PND, no
    orthopnea, no easy
    fatigability, no syncope,
    hypertensive: 130-140/80-
    90
    chest pain/ easy
    fatigability/nocturnal/dyspnea/
    orthopnea/palpitations/syncope/
    edema/hypertension/others
    VASCULAR
    no phlebitis, no varicosities,
    no claudication

    no phlebitis, no varicosities,
    no claudication
    phlebitis/varicosities/claudication/
    others
    GASTRO-INTESTINAL
    no abdominal pain, no
    vomiting, no diarrhea, no
    constipation, no melena, no
    hematochezia

    no abdominal pain, no
    vomiting, no diarrhea, no
    melena, no hematochezia,
    with constipation
    nausea/vomiting/retching/
    hematemesis/melena/hematochezia/
    dysphagia/belching/indigestion/food
    intolerance/flatulence/abdominal
    pain/distention/constipation/ anal
    lesions/others
    GENITO-URINARY
    no incontinence, no
    urgency, no frequency, no
    dysuria, no nocturia, no
    flank pain

    no incontinence, no
    urgency, no frequency, no
    dysuria, no nocturia, no
    flank pain, with diaper
    urinary frequency/urgency/
    hesitancy/dysuria/hematuria/nocturia/
    urine system flow abnormality/flank
    pain/stones/urethral discharge/genital
    lesions/testicular mass/perineal pain/
    impotence/vaginal discharge/abnormal
    bleeding/others
    MUSCULOSKELETAL
    no muscle pain, no
    weakness, no numbness

    with muscle weakness
    especially on right side
    joint stiffness/pain/swelling/muscle
    pain/cramps/weakness/wasting/
    trauma/abnormal posture/others
    ENDOCRINE
    no polydipsia, no polyuria,
    no heat and cold
    intolerance, no hoarseness

    no heat and cold tolerance,
    diabetic since 2012 (CBG:
    156)
    heat-cold intolerance/thyroid
    problems/voice change/diabetes or
    diabetic indicators/neck surgery/or
    radiation/others
    HEMATOPOIETIC
    no bruising, no bleeding
    tendencies, no anemia

    no bruising, no bleeding
    tendencies, no anemia
    abnormal bleeding/bruising/
    anemia/adenopathy/others
    NEUROLOGIC
    awake, conscious, GCS 15

    lethargic, conscious, GCS 10 headache/seizure/sensory perversion/
    motor dysfunction/speech
    disturbance/mental changes/head
    trauma/others
    (E4V5M6) fairly kempt, very
    dysarthic, cooperative, with
    eye contact, follows
    commands
    Cerebellum: (-) dysmetria, (-
    ) dysdiadokinesia

    Cranial Nerves:
    CN I: not assessed
    CN II: pupils 2-3mm ERTL
    CN III, IV, VI, EOM full and
    equal, (-) diplopia, (-)
    nystagmus
    CN V1V2V3: intact
    CN VII: (+) central facial
    palsy, right
    CN VIII: intact gross hearing
    CN IX, X: tongue protruded
    towards the right, (+) gag
    reflex
    CN XI: can turn head again
    resistance
    CN XII: shrug shoulder,
    weaker right
    Motor: 1/5 on RUE and RLE,
    5/5 on LUE and LLE
    Sensory: no sensory deficit
    DTRS: +++ on RUE and RLE,
    ++ on LUE and LLE
    Pathological Reflexes: (+)
    Babinski Reflex, right
    Meningeal signs: (-) nuchal
    rigidity, (-) Kernig sign, (-)
    Brudzinski sign
    (E4V1M5) very dysarthic,
    uncooperative, with no eye
    contact, follows some
    commands

    Cranial Nerves:
    CN I: not assessed
    CN II: pupils 2-3mm ERTL
    CN III, IV, VI, EOM full and
    equal on left side, (-)
    diplopia, (-) nystagmus
    CN V1V2V3: intact
    CN VII: (+) central facial
    palsy, right
    CN VIII: intact gross hearing
    CN IX, X: tongue protruded
    forward
    CN XI: difficulty in turning
    the head to the right
    CN XII: shrug shoulder,
    weaker right
    Motor: 1/5 on RUE and RLE,
    5/5 on LUE and LLE
    Sensory: cant feel light
    touch on RUE and RLE
    DTRS: +++ on RUE and RLE,
    ++ on LUE and LLE
    Pathological Reflexes: (+)
    Babinski Reflex, right
    Meningeal signs: not
    assessed
    PSYCHIATRY
    no anxiety, no depression

    not assessed anxiety/depression/interpersonal
    relationship
    difficulties/illusion/delusion/hallucination/
    paranoia/others

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