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    Complete ROS and PE

    Uploaded by

    Julienne
    The document provides a review of systems and physical examination for a patient presenting with a toothache. On physical examination, the patient is alert and oriented with abrasions on the wrists, legs, and right eye/temple. Vital signs are stable. Examination of the head, eyes, ears, nose, throat, lungs, heart, abdomen, back, joints and nerves is largely unremarkable except for enlarged thyroid and reddened throat. Cranial nerves are intact and the patient is alert and oriented.

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    Complete ROS and PE

    Uploaded by

    Julienne
    335 views6 pages
    The document provides a review of systems and physical examination for a patient presenting with a toothache. On physical examination, the patient is alert and oriented with abrasions on the wrists, legs, and right eye/temple. Vital signs are stable. Examination of the head, eyes, ears, nose, throat, lungs, heart, abdomen, back, joints and nerves is largely unremarkable except for enlarged thyroid and reddened throat. Cranial nerves are intact and the patient is alert and oriented.

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    Complete ROS and PE

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    The document provides a review of systems and physical examination for a patient presenting with a toothache. On physical examination, the patient is alert and oriented with abrasions on the wrists, legs, and right eye/temple. Vital signs are stable. Examination of the head, eyes, ears, nose, throat, lungs, heart, abdomen, back, joints and nerves is largely unremarkable except for enlarged thyroid and reddened throat. Cranial nerves are intact and the patient is alert and oriented.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    335 views6 pages

    Complete ROS and PE

    Uploaded by

    Julienne
    The document provides a review of systems and physical examination for a patient presenting with a toothache. On physical examination, the patient is alert and oriented with abrasions on the wrists, legs, and right eye/temple. Vital signs are stable. Examination of the head, eyes, ears, nose, throat, lungs, heart, abdomen, back, joints and nerves is largely unremarkable except for enlarged thyroid and reddened throat. Cranial nerves are intact and the patient is alert and oriented.

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    Review of Systems:

    General  Toothache (Left molar tooth)


     Fever
     Fatigue Breast
     Weakness  Lumps
     Recent weight change  Pain
     Nipple discharge
    Integumentary
     Rash Respiratory
     Erythema  Dyspnea
     Pruritus  Cough
     Hair and nails changes  Chest pain
     Changes in sizes and color of moles  Hemoptysis
     Wheezing
    Head and Neck
     Headache (2/10) Cardiovascular
     Dizziness  Dyspnea
     Injury  Orthopnea
     Easy fatigability
    Eyes  Edema
     Pain  Palpitation
     Redness  Chest pain
     Loss of vision  Paroxysmal nocturnal dyspnea
     Itching
     Dryness Gastrointestinal
     Excessive lacrimation  Nausea
     Corrective lenses  Vomiting
     Constipation
    Ears-Nose-Throat-Mouth  Diarrhea
     Tinnitus  Abdominal pain
     Loss of hearing  Hematemesis
     Otalgia  Hematochezia
     Otorrhea  Flatulence
     Epistaxis
     Anosmia Genitourinary
     Hoarseness  Dysuria
     Dysphagia  Frequency
     Sore throat  Dribbling
     Bleeding gums  Discharge
     Loss of taste  Hematuria
     Dryness of mouth
     Sores/patches in mouth Musculoskeletal
     Myalgia Endocrine
     Arthritis  Weight change
     Weakness on his left knee but  Heat and cold intolerance
    tolerable  Hyperhidrosis
     Joint stiffness  Polydipsia, polyphagia, polyuria
     Cramps
     Backache Nervous
     Headache
    Hematologic  Syncope
     Anemia  Seizure
     Easy bruising  Weakness
     Bleeding  Numbness
     Memory loss

    Physical Examination
    GENERAL: Patient is a young, healthy looking male, about 5 feet tall. Alert. Answers our question
    coherently. No malodorous scent, hair length was not assessed due to the bandage on his head.
    Hospital gown. Patient is on sitting position. Pt was not asked to walk. Gait was not assessed. Has no
    involuntary movement or gross deformity and slightly in pain (headache) 4/10. He has a dark
    complexion. Abrasions on the wrist area 3 cm x 51.5 cm, 2 abrasions on the popliteal area. 1 cm
    abrasion on the right eye, abrasions on the right temporal area (4 x 3 cm)

    Vital signs

    1. Blood Pressure: 110/80


    2. Heart Rate & Rhythm
    a. Pulse rate: 70
    b. Cardiac Auscultatory Rate: 67 bpm
    3. Respiratory Rate, Depth and Regularity
    17 bpm, regular rhythm
    4. Temperature: 36.3 C

    5. Pain Scale: --

    SKIN

    Skin is dark complexion, slightly cold to touch.

    HEAD, EYES, EARS, NOSE, THROAT & NECK

    Head: Face is symmetrical with no involuntary movements while skin is dark.

    **PE on the head was not fully assessed because gauze is drained with blood and delicate-looking.
    The Eyes: symmetrical eyebrows, equally distributed hair. Symmetrical eyelids. White sclera and
    pink palpebral conjunctiva, clear cornea and lens. Pupils are reactive to light. No visual defects noted
    on confrontation test. Intact EOM. No hemorrhage or exudates noted

    The Ears: Symmetrical ears, non-tender auricle.

    The Nose: Symmetrical nose, nasal pages are patent, septum at midline.

    The Throat: Dry lips, without lesions, reddish oral mucosa, pinkish gum, white teeth, hard palate Is
    high arch. Symmetrical tongue in protrusion, uvula at midline. Tonsils are enlarged reddish pharynx
    with no lesions

    The Neck: neck is non-tender with no palpable mass or lymph adenopathy, Thyroid is diffusely
    enlarged, firm, non-tender and moves deglutition, no bruit noted. Trachea is on midline

    CHEST AND LUNGS

    Thorax is symmetrical in expansion, no deformity. No widening ICS, no retractions. No visible mass.


    Quiet breathing. Without pain. No rales, wheezes or rhonchi.

    CARDIOVASCULAR

    No bluging of precordum, absence of lesions, thrills, heaves or lift and tenderness

    GASTROINTESTINAL:
    Symmetrical, globular in shape, abdominal movement is synchronized with respiratory breathing.
    No visible pulsations, no peristaltic movement, umbilicus is midline and inverted.

    Bowel sounds are 5/min. No borborygmus. No bruits, no friction rubs on hepatic or spleenic areas

    Tympanic in all quadrants, liver span is on midclavicular line right. Traube’s space is not obliterated
    and negative kidney punch test

    On light palpation, abdomen is soft in all quadrants, no area of tenderness, superficial masses or
    organ. On deep palpation, liver has smooth with regular borders. No rebound tenderness. No deep
    masses. no organomegaly

    (-) fluid wave test, no shifting dullness. Upon palpation on appendix, there is no rebound and direct
    tenderness, (-) raving’s sign, (-) psoas sign, (-) obrturator sign, no cutaneous hyperesthesia. (-)
    murphy’s sign

    MUSCULOSKELETAL:

    MUSCULOSKELETAL
    Temporomandibular joint: Symmetrical face, no swelling, no redness of joint, non-tender
    joint. Smooth range of motions.

    Shoulder: Symmetrical with intact bony structures. No swelling, redness


    or deformity noted. No tenderness noted. Can do shoulder
    movement as to flexion and extension, abduction and
    adduction and internal and external rotation without
    difficulty
    Elbow: Intact medial and lateral epicondyle and olecranon processes,
    non-tender not swollen; can do flexion, extension, and
    supination and pronation without difficulty

    Wrist and hands: Hand movements are smooth and natural, no swelling nor
    deformities noted. Can do flexion, extension, adduction and
    abduction without difficulty.

    Spine: Looking at the side, there is cervical and lumbar concavities


    and thoracic convexity. Equal shoulder height. No skin lesion
    or swelling noted. No tenderness or spasm noted.

    Hip: No tenderness, swelling or body prominence abnormalities


    noted. Gait is smooth with maintained balance with
    symmetrical leg length

    Knee: Symmetrical with no swelling or redness noted. No area of


    tenderness. Can do flexion, extension, internal and external
    rotation.

    Ankle and foot: The surfaces are smooth with no obvious lesions. No swelling
    or tenderness noted. Dorsalis pedis and posterior tibial pulses
    are equal. Can do flexion and extension, inversion and
    eversion without difficulty.

    CENTRAL NERVOUS SYSTEM

    Mental Status: Alert, relaxed, and cooperative. Oriented to person, place, and time. No illusion or
    hallucinations. Knows what was done to him and recalls the main reason of his admission. His
    responses to family or personal situation are appropriate. Cooperative and jolly.

    Cranial nerves

    I Can smell on both nostrils


    II no visual defects on confrontation test. Fundoscopy was not done
    III Both pupils reactive to light. Intact direct and conjugate papillary
    reflex
    III, IV, VI intact EOMs. No nystagmus, strabismus and ptosis noted
    V Sensations on the face present. Temporal and masseter strength
    intact. Can clench his teeth with positive corneal reflex on both eyes.
    Blink both eyes normally.
    VII symmetrical face can raise both eyebrows, can smile and frown and
    puff out both cheeks
    VIII – (-) Weber’ test, Rinne’ test, (AC>BC) on both ears. Can hear snapping
    finger at a distance of 1 foot whispered words and rubbing of hair
    strands
    IX, X – Can swallow without difficulty. No dysphonia, no uvula deviation. Soft
    palate rises symmetrically. Gag reflex present
    XI – symmetrical, can shrug both shoulders, able to move head
    XII – can protrude tongue. No tongue deviation
    Cerebellar: can do tandem walking. Romberg’s test is negative

    Meningeal: No nuchal rigidity, (-) Kernerg’s sign, (-) brudzinski’s sign

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