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fammyBIOGRAPHICAL DATA / REVIEW OF SYSTEM

SYSTEM METHOD USED REMARKS


>No rashes >Normal
Skin, Hair and Inspection >No lesions >Normal
Nails >No excessive sweating >Normal
>No hair loss >Normal
>No dandruff >Normal
Head >No headache >Normal
and Inspection >No stiffness >Normal
Neck >No difficulty in swallowing >Normal
>No enlarged lymph nodes >Normal
>No pain >Normal
>No ringing >Normal
Ears Inspection >No buzzing >Normal
>No difficulty in hearing >Normal
>No dizziness >Normal
>No pain >Normal
>No infections >Normal
>No redness >Normal
>No tearing >Normal
Eyes Inspection >No halos >Normal
>No blurring >Normal
>No black spots >Normal
>No flashes >Normal
>No double vision >Normal
>No mouth pain >Normal
>No sore throat >Normal
Mouth, Throat, Inspection >No lesions >Normal
Nose and Sinuses >No hoarseness >Normal
>No nasal obstruction >Normal
>No sneezing >Normal
>No coughing >Normal
>No snoring >Normal
>No nosebleeds >Normal
>No pain >Normal
>No difficulty in breathing >Normal
>No shortness of breath >Normal
with activities
Thorax/Lungs Auscultation >No orthopnea >Normal
>No cough >Normal
>No sputum >Normal
>No hemoptysis >Normal
>No respiratory infections >Normal
>No pain >Normal
>No lumps >Normal
Breast and >No discharge from breast > Normal
Regional Inspection >No changes in breast >Normal
Lymphatics size
>No swollen tender lymph >Normal
nodes in axilla
>No chest pain >Normal
>No edema >Normal
Heart and Neck Auscultation >Last blood pressure was
Vessels Palpation 110/90
>Last ECG was normal to >Normal
CP clearance
Peripheral >No leg pain >Normal
Vascular Inspection >No swelling of leg >Normal
>No sore on leg >Normal
> Suffer from abdominal >Abnormal
pain because of his
Inspection condition; describes pain
Palpation as sharp with vague
Abdomen Auscultation sensation of
Percussion discomfort/distress.
Manifested facial
grimacing, guarding of
affected area.
>No painful urination >Normal
>No difficulty in urination >Normal
>No blood in urine >Normal
>No sexual problem >Normal
Male Genitalia Inspection >No penile lesions >Normal
>No penile pain >Normal
>No scrotal swelling >Normal
>No difficulty with erection >Normal
>No exposure to sexually >Normal
transmitted diseases
>No pain >Normal
Anus >No hemorrhoids >Normal
Rectum Inspection >Bowel habits is normal >Normal
Prostate >No constipation >Normal
>No diarrhea >Normal
>No blood in stool >Normal
>No pain >Normal
Percussion and >No swelling >Normal
Musculoskeletal Inspection >No stiff on joints >Normal
>No weakness of > Normal
extremeties
>Behavior is good >Normal
>No depression >Normal
>No anger >Normal
Neurological Inspection >No loss of sensation >Normal
>No difficulty with speech >Normal
>No memory problems >Normal
>No strange actions >Normal
>No difficulty in reading >Normal

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