REVIEW OF SYSTEMS:

I. Health in General

Patient HEA was experiencing lack of energy, fatigue and night sweats. According to her, she often
experience having a fever during morning and at night. She also added that she sometimes experience
loss of appetite. Patient HEA does not experience scalp tenderness and she doesn’t have prior diagnosis
of cancer.

II. Integumentary (Skin, Hair, Breast)

Patient HEA was experiencing itching on her lower extremities. According to her, she started
experiencing it since her 2nd day of admission in the hospital. Patient HEA also has a lump on her upper
back which is painful whenever she lies on a long period of time. She also experience dryness of the oral
mucosa or the lips. Patient HEA was experiencing soreness of the left arm and hand (upper extremity)
and was painful during palpation. Patient HEA’s IV insertion site was also swelling. Patient HEA does not
experience rashes, color changes in nails and hair, changes in size or color of moles, no changes in breast
and in existing skin lesion and no hair loss or increase hair.

C. Head, Eyes, Ears, Nose, Throat (HEENT)

According to Patient HEA, she was experiencing dizziness and lightheadedness. Patient HEA is a
farsighted person but she never had an eye examination or check-up before. She had never worn any
glasses and contact lenses before. According to her, she was experiencing pain in her eyes if there’s too
much light. She was also experiencing blurring of vision and flashing light sometimes. Patient HEA does
not experience earache, ear infection, difficulty with hearing, vertigo, discharge and she does not use
hearing aid. Patient HEA added that, she was experiencing frequent colds and nasal stuffiness. She also
said that she was experiencing nasal itching when there’s a nasal cannula inserted to her nose. Patient
HEA has a partial denture in the front part.

D. Respiratory (Lungs and Breathing)

Patient HEA verbalized that she was experiencing shortness of breath, night sweats and prolonged
cough. She also added that there is no sputum production. According to her, whenever she experience
difficulty of breathing, wheezing is present.

E. Cardiovascular (Heart and Blood Vessels)

Patient HEA was experiencing chest pain or discomfort whenever she coughs. She was also experiencing
pain in legs when walking. Patient HEA added that she was experiencing dyspnea. She also has
peripheral edema.

F. Gastrointestinal

According to Patient HEA, she was experiencing heartburn usually at morning. She was also experiencing
abdominal pain. She also added that she always burps.
G. Genitourinary (Kidney and Bladder)

Patient HEA said that she was experiencing frequent urination. She also added that, she was
experiencing nocturia that’s why she doesn’t have enough sleep. Patient HEA also has Urinary Tract
Infection.

H. Genital

According to Patient HEA, she does not experience dysmenorrhea during her menstrual period.
According to her, she was experiencing premenstrual tension because she became irritable and
experience breast pain before menstruation.

I. Peripheral Vascular

According to Patient HEA, she was experiencing sudden spasms or leg cramps when walking. She was
also experiencing intermittent claudication even though she’s just lying on the bed.

J. Musculoskeletal (Muscles, Bones, Joints)

Patient HEA was experiencing muscle or joint pain and stiffness on her lower extremities. She also added
that she was experiencing low back pain. She said that she experience joint pain when she has fever and
chills.

K. Psychiatric (Mood and Thinking)

Patient HEA said that she was experiencing difficulty of sleeping or staying asleep because of frequent
urination and abdominal pain. She also feels irritable. According to her, she was very worried on her
condition and on her live-in partner who does not have enough rest and sleep because he was always
with her. She was experiencing mood swings. According to her, she was experiencing compulsions
because sometimes she experience an irresistible urge to do something such as walking by herself and
eating.

L. Neurologic (Brain and Nerves)

Patient HEA was experiencing weakness. According to her, she has problem in walking or balance
related to weakness that’s why her live-in partner always assist her when using the toilet. She was also
experiencing paresthesia on her feet.

J. Hematologic (Blood/Lymph)

According to Patient HEA, she does not have anemia, past transfusion, easy brushing or bleeding and
transfusion reaction.

K. Endocrine (Glands)

According to Patient HEA, she was always thirsty and hungry. She was also experiencing polyuria.
L. Allergic/ Immunologic

According to Patient HEA, she was experiencing itching on her legs. She does not have seasonal allergies,
hay fever symptoms, exposure to HIV and frequent infections.

PHYSICAL ASSESSMENT

I. Physical Presence

Patient HEA is a 39 year old woman. Her stated chronological age is congruent with the apparent age.
There are no obvious deformities and the patient has a well appearance. She also does not have foul
body odor. Her body fats are evenly distributed. Patient’s posture is erect. She was being assisted by her
husband when she walks.

II. Psychological Presence

Patient HEA wears clean and neat clothing. She is cooperative in which she responds to commands and
answers questions quickly. She is sometimes pleasant to talk to and sometimes irritable. She speaks
clearly in which her voice has normal pitch, rate and volume that’s why it is easy to understand what
she’s saying. Patient HEA has facial grimace whenever she was in pain. Her facial expression is
appropriate on what is happening on her environment and changes naturally. Patient HEA is awake and
alert.

III. Distress

She was experiencing labored breathing and cough. Patient HEA has painful facial expression, sweating
and has a guarding behavior on her abdomen and left upper extremity (arm). Her Respiratory Rate is
above the normal range.

IV. Skin

The patient has a smooth and fair skin. Dark skin can be observed under her eyes due to her eyebags.
She was experiencing pain and swelling on her left toe. The patient does not have any lesion. She has
three purple-greenish colored bruises on her right arm. She was experiencing tenderness on her left
arm and hand since it was painful during palpation. Patient HEA has peripheral edema. She has a pitting
edema. Her skin oh her legs and arms feel puffy and tight. She has normal skin turgor on area that does
not have edema. She was experiencing hyperthermia.

V. Hair

Patient HEA has a black hair. According to her, she uses black hair color for almost 8 years. She has a
brown eyebrow tattoo.