REVIEW OF SYSTEMS:

General: 10% weight loss, easy fatigability and body weakness, afebrile.

Skin: No rashes, no itchiness, no lumps, no sores, no dryness.

Head: No light headedness, no headache, no head injury, no dizziness.

Eyes: Blurring of vision, no excessive tearing, no double vision, no eye pain.

Ears: No tinnitus, no earaches, no vertigo, no discharges, with good hearing.

Nose & Sinuses: No nasal stuffiness, no discharges, no itchiness, no epistaxis.

Mouth & Throat: With dry mouth, no sore throat, no hoarseness, no bleeding gums.

Neck: No stiffness, no lumps, no swollen glands.

Breast: No pain or discomfort, no nipple discharge, no lumps.

Respiratory: With difficulty of breathing, orthopnea, paroxysmal nocturnal dyspnea,

and nocturnal cough.

Cardiac: With chest pain, palpitations, sitting orthopnea, and bilateral edema

GIT: With loss of appetite, no abdominal pain, no vomiting, no dysphagia, no diarrhea, no constipation.
Defecates once a day to a formed yellowish stool.

GUT: Urinates 3-4 times a day with characteristic yellow urine approximately 200 cc per urination, no
nocturia, no dysuria, no hematuria nor polyuria.

Genital: No discharges, no dyspareunia, no itchiness.

Peripheral Vascular: With bilateral dependent pitting edema, no intermittent claudication and leg cramps,
no tenderness.

Musculoskeletal: No joint nor muscle pain, no swelling, no tenderness, no stiffness.

Neurologic: No fainting, no seizure, no numbness, no tremors, no tingling sensation, no blackouts, no

involuntary movements.

Hematologic: No easy bruising, no bleeding tendencies.

Endocrine: No heat or cold intolerance, no excessive thirst or hunger.

Psychiatric: No mood swings, no nervousness, no depression, no suicidal attempts or tendencies.

PHYSICAL EXAMINATION:

General survey:
The patient is an ectomorphic elderly female, in sitting position when examined. The patient was
conscious, coherent, oriented to time place and person, cooperative, afebrile, ambulatory. The patient
appears to be in no distress at rest except for feeling uncomfortable when lying flat for more than a few
minutes. She is neatly dressed, well-groomed, with no body odor and halitosis.

Vital Signs:
Temp: 36.4 °C
BP:
PR:
RR:

Integument:
Skin: Dark complexion, no scars, with good skin turgor, no hypo/hyperpigmentation, no rashes,
no lesions, with bilateral pitting edema.
Nails: Slightly pale, no clubbing, no ridges, with good capillary refill of <3 seconds

Head:
Scalp: no engorged veins, no scars, no active lesions, no seborrheic dermatitis, no tenderness, no
mass.
Hair: black with white streaks, fine, wavy, evenly distributed, no lice or nits.
Eyes:
Eyebrow: symmetrical, evenly distributed, black, no active lesions, no scars.
Eyelashes: 2 rows of fine, black hair, evenly distributed, oriented outward.
Eyelids: no lidlag, no ptosis, no sty, no xanthelasma, no periorbital edema, no tenderness, no
lesion.
Pupils: symmetrical, about 3 mm in diameter, briskly reactive to direct and consensual light reflex.
Conjunctiva: pinkish palpebral conjunctiva, no hemorrhage.
Cornea: no opacities of both eyes, no scars, no ulceration, no lesion.
Sclera: anicteric, no hemorrhage, no lesion.
EOM: intact and full movements.

Ears: symmetrical, no tophi, no abnormal discharge, no swelling, no tenderness, no hearing loss.

Nose: no septal deviation, pinkish mucous membrane, no flaring of ala nasi, no lesion, no discharges, no
congestion.

Sinuses: no tenderness, no frontal or maxillary sinusitis.

Mouth and Throat

Lips: non cyanotic, no lip sore, no angular deviation, with dryness.
Teeth: incomplete set, with dental carries.
Tongue: pinkish at midline upon protrusion, with white patches, no fissure, no ulceration, no
papillary atrophy
Gingiva and Mucous membrane: pinkish mucous membrane, no bleeding, tonsils not enlarged,
no peritonsillar plaque, uvula at midline.
Neck: no venous engorgement, no visible pulsation, trachea at midline, no nuchal rigidity, no bruit, no
pain, thyroid not enlarged.

Lymph Nodes: no lymphadenopathies.

Breast: symmetrical, no lumps, no nipple discharge, no pain, no discomfort, no mass.

Chest and Lungs:

Inspection - Symmetrical lung expansion, truncal, no lagging, no bulging, no abnormal contour, no
intercostal and subcostal retraction, with slight use of accessory muscles of respiration.
Palpation - no tenderness, no masses, no lagging, unaltered tactile fremitus.
Percussion –dullness on the left lower lung field, resonant on other lung fields
Auscultation - decreased breath sounds on the left lower lung field, no rales, no wheeze, no
pleural friction rub

Heart:
Inspection – No precordial bulging, with visible pulsation on the xiphoid area
Palpation -No thrill, no heaves, PMI palpable at 6th ICS L AAL.
Auscultation- S1 is louder than S2 at tricuspid and mitral area. S2 is louder than
S1 at aortic and pulmonic area. HR is ___ bpm and synchronous with pulse,
normal regular rate and rhythm, no pericardial friction rub.

Abdomen:
Inspection - Flat, symmetrical, with visible pulsation on xiphoid area, no venous engorgement, no
active lesion, with stretch marks.
Palpation – No tenderness and muscle guarding. The liver, spleen, and kidneys are not palpable.
Percussion – Tympanitic in all regions. Liver span approximately 7 cm.
Auscultation (-) shifting dullness. 8 bowel sounds per minute, no arterial bruit, no venous hum,
no peritoneal friction rub.

Genitalia: Grossly female, no lesions, no discharges.

Back & Spine

Inspection - Symmetrical, no abnormal deviation, no retractions and bulging.
Palpation – Non tender no paravertebral mass.

Extremities:
Inspection – With bilateral pitting edema predominantly in the ankles, no cyanosis, no atrophy.
Palpation - No muscle tenderness, right and left brachial pulses 2+, femoral pulses 2+, popliteal
pulse 2+, and pedal pulse 2+.

NEUROLOGIC EXAMINATION:
 Mental Status Exam:
Patient was examined conscious, coherent, attentive, oriented to time, place, and person,
with good and intact memory, and able to count, read, write, and speak. No hallucinations,
delusions, nor mood swings.

Cranial Nerves:

CN I – No anosmia.
CN II and III – Pupils are equally round (3mm) and briskly reactive to direct and consensual light stimulation
and accommodation.
CN III, IV, VI – Intact & full movement following the 6 cardinal movements of gaze.
CN V – Able to clench teeth, responds to sensation when eyes are closed, (+) corneal reflex manifested by
blinking after touching sclera with wisp of cotton (sensory).
CN VII – No facial asymmetries, able to smile, frown, blow, & whistle.
CN VIII – Responsive to verbal stimuli, with eyes closed the patient is able to follow sounds like clicking of
fingers.
CN IX and X – Able to swallow, (+) gag reflex.
CN XI – Able to turn head to sides against resistance, able to shrug shoulders against resistance.
CN XII – Protrudes tongue without deviation to left or right, able to move tongue up, down, and laterally.

MOTOR: Able to extend both wrists; grip both hands; abduct and adduct fingers; flex, extend, and laterally
bend trunk; flex and extend knees, plantar flex and dorsiflexes ankles.

5/5 5/5

5/5 5/5

5/5 5/5
5/5 5/5

Sensory: Able to identify traced numbers and letters on palms of both hands; able to identify position of
extremities (up or down) while eyes closed; able to identify 2 point discrimination.

Reflexes:

Deep Tendon Reflexes

Biceps – (++) symmetrical on both extremities
Triceps – (++) symmetrical on both extremities
Knee – (++) symmetrical on both knees
Ankle – (++) symmetrical on both ankles

Cerebellar Tests:
Knee Pat test – Able to pat knees with both hands on palms and dorsum of hands alternately.
Finger to nose – Able to touch examiner’s finger then back to her nose