Review of Systems

General: + weight change; good appetite,

Skin: no pigmentation & hair loss.
HEENT
Head: no headache, dizziness;
Eyes: had a clear vision
Ears: no earaches, discharges
Nose: no nasal stuffiness, discharge, itching
Throat: no bleeding, ulcers, sores
Neck no lumps, stiffness
Respiratory: no dyspnea, cough
 Cardiovascular: no fainting
Gastrointestinal: no nausea, vomiting, diarrhea, passage of
worms, abdominal pain, food intolerance.
Urinary: yellow urine, no burning sensation & discharge
Genital: no rashes & itchiness
Musculoskeletal: No pain or swelling.
Neurologic: No personality changes
Hematologic: no bruises, pallor and bleeding manifestations
Endocrine: no heat/cold intolerance
Physical Examination

GENERAL SURVEY
drowsy, slight respiratory distress
VITAL SIGNS
Temp: 33.9˚C
HR: 150 bpm
RR: 58 cpm
 Physical examination
ANTHROPOMETRIC DATA
Wt: 6 kg
Length: 77 cm
Chest Circumference: 48 cm
Head Circumference: 47 cm
Abdominal circumference: 46 cm
Weight for age: below-3: severely underweight
Head circumference for age: below -3:
Weight for length: below -3: severe wasting
Length for age: below-3: severe stunting
 Physical Examination
SKIN:
warm, good skin turgor, no lesion
HEENT
Head: normocephalic, hair is fine, black, well distributed. No
infestation and swelling.
Face: symmetric, no deformities, and lesions
Eyes palpebral conjunctivae are pinkish, no lesions.
Ears and mastoids: helix of the ear is in line with the inner and
outer canthi, no discharges, tags and pits
Nose and paranasal: no alar flaring, discharge. Septum is intact.
Mouth and throat: lips are pinkish; gums are pinkish, no lesions
and bleeding
 Physical examination

NECK
No lymph nodes palpated, venous engorgement, rigidity, swelling.
Thyroid is not palpated.
CHEST AND LUNGS
+ chest indrawing and intercostal retractions; + rales in both lung
fields; both lungs are resonant upon percussion.
CARDIOVASCULAR
PMI is palpable at 4th left intercostal space midclavicular line. Had
regular rate and rhythm, no murmurs heard.
ABDOMEN
Distended, nontender, active bowel sounds, no prominent vessels,
striae and pulsation. Tympanitic upon percussion, except over liver
and bladder areas, are dull. Umbilicus is not inflamed, no
discharges seen.
 Physical Examination

GENITALIA: Penis is more than 5 cm; no

lesions, phimosis, hypospadias and
epispadias. Testicles are in the scrotum,
presence of rugae; no hydrocele and
hernia.
BACK: No deformities and lesions.
EXTREMITIES: Symmetric; no deformities,
clubbing, cyanosis, and edema
 NeurologicExam

CRANIAL NERVES:
I: sense of smell is intact
II,III: able to fixate on the human face
III,IV,VI: Doll’s eye test is positive
V: able to grimace and symmetric
VII: face is symmetric
VIII: Able to hear, will turn his head when heard
something
IX,X, XII: able to breastfed
XI: rotate head against resistance
 MOTOR:
Muscle strength:

Right & left arms - Gross movements against

full resistance – full strength
Right & left legs - Gross movements against
light resistance –full strength