Student: __NEIL MICHAEL SUAREZ___ Group: GROUP B__
Mindanao State University – Iligan Institute of Technology Inclusive Dates of Duty: ______________________________
Patient: __________________________ Room No.: _______
MATERNAL AND
CHILD
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
Vital Signs:
Temp: _38°C___ RR: __________ Weight: _____________
PR: __________ BP: __________ Height: ______________
Chief Complaint/s: _______Urinary frequency and burning upon urination_____________________________ Impression/Diagnosis: ____Recurrent Urinary Tract Infection______________
1. General (weight loss or gain; fever, chills, A 67 years old male patient,
night sweats; mood; stage of development,
race, sex; signs of distress; position;
cooperative or not; state if irritable, agitated
or pleasant; etc.)
2. Head (headache, injury, tenderness, etc.);
Eyes (change in visual fields, glasses,
blurring, diplopia, pain, loss of vision,
tearing, dry eyes, etc.); Ears
(change in hearing, tinnitus, discharge,
dizziness, etc.); Nose (allergies, sinus
problem, obstruction, polyps, sneezing,
epistaxis,etc.);Throat (toothaches, loose
teeth, bleeding gums, mouth sores,
Hoarseness, difficulty swallowing, etc.)
3. Integumentary System
4. Respiratory System The patient reveals decrease breath sound of the right base of the lungs in the course of assessment, The patient presents productive cough with presence of green
(Chest pain, dyspnea, cough, amount and sputum upon obtaining culture sample, shortness of breath was also noted upon assessment with an 85%, SaO (room air temperature).
2
color of sputum, hemoptysis, etc.)
5. Cardiovascular System (chest pain/ The patient shows shortness of breath (dyspnea) upon auscultation. No chest pain and edema are noted.
pressure/ tightness, palpitations, orthopnea,
paroxysmal nocturnal dyspnea, shortness of
breath, edema, claudication, endurance, etc.)
6. Digestive System
(dysphagia, heartburn, ulcer, GERD,
indigestion, food intolerance, diarrhea,
constipation, abdominal pain, blood in stool,
black tarry stools, changes in bowel habits,
reduced caliber of stools, hemorrhoids, etc.)
7. Excretory System The patient complained of Urinary frequency and burning upon urination upon admission with a history of Benign Prostatic Hypertrophy.
(urgency, frequency, nocturia, dysuria,
hematuria, recurrent UTIs, STD,
Incontinence, etc.)
8. Musculoskeletal System (limitation in
movement, stiffness, joint pain, swelling or
redness, arthritis, muscle spasms, muscle
weakness, etc.)
9. Nervous System
10. Endocrine System
(Heat/cold intolerance, weight change,
fatigue, polydipsia, polyuria,
polyphagia, changes in hair distribution, etc.)
11. Reproductive System
