REVIEW OF SYSTEMS

GENERAL: (+) Weight Loss ( 15 kgs to 13 kgs)

(+) Fever / Night Sweats
(+) decreased activity level
(+) decreased appetite ( Able to drink 1 glass, now only )
(-) delay in growth

CUTANEOUS: (-) moist

(-) rash
(-) depigmentation
(-) hair loss
(+) Pallor
(+) Paleness

HEENT:
(+) Cracking of Lips
(+) Swollen Lips
(+) Unilateral Neck Swelling / Cervical Lymphadenopathy
(-) ear discharges
(-) nasal discharges
(-) epistaxis
(-) excessive salivation
(-) frequent aspiration

RESPIRATORY: (+) cough

(-) chest pain
(+) dyspnea
(-) Hemoptysis
CARDIOVASCULAR:
(+)cyanosis
(+) easy fatigability
(-)fainting spells
(-)murmurs
(-)edema of hands and feet

GASTROINTESTINAL:
(+) constipation
(-) diarrhea
(+)abdominal pain
(-)food intolerance

GENITOURINARY: (+)change in urine color Light Brown

(-)discharges
(-)foul smell

NERVOUS/BEHAVIORAL: (+)irritability
(-)convulsions
(+)weakness

MUSCULOSKELETAL: (-) uneven tone

(-)edema
(-)limping

HEMATOPOIETIC: (+)pallor
(-)bruising
(-)blood in stool

PHYSICAL EXAMINATION

General Survey

Patient was awake, lying on bed, wearing clean and dry clothes. Patient is irritable but not in cardiopulmonary distress.
Patient was attached to IV fluid of Plain NSS at Right metacarpal vein and Nasal Cannula attach to O2 tank @ 2 LPM.

Vital Signs
 Temperature: 37.3 Afebrile

Cardiac Rate: 112 Tachycardic

Respiratory Rate: 32 Tachypnea

Blood Pressure: not assessed

Anthropometric measurements

Weight: 13 kgs; z-score=0 Normal

Length: 87 cm; z-score=0 Normal

BMI:

Z-score for weight for height is 0 and is interpreted as normal.

Skin

Patients skin is fair, without bruises, lesions or edema. No cyanosis or jaundice was noted. Fingers and toes appear to be
pale. No skin desquamation or scaling was noted. Skin was cool to touch, with good skin turgor, and capillary refill of less than 2
seconds. No lumps or tenderness noted.

Head

Head is normocephalic and without abnormal contour or shape. Hair is black and evenly distributed. No lice, nits, or
dandruff noted. No lesions or masses was noted. Posterior fontanel is closed while anterior fontanel is open and flat.

Eyes

Eyes are symmetrical and without ptosis or periorbital edema noted. Eyelashes are equally distributed and without
crusting. No redness of eyes noted. Conjunctiva was slightly pale and sclera was anicteric. Pupils were equally round and reactive
to light and accommodation. Patient was able to follow cardinal gazes.

Ears

Ears are symmetrical and without deformities. Minimal cerumen was noted in the patients external ear canal. No
abnormal discharges was noted. No mass or lumps was noted on the patients postauricular and mastoid area; no tenderness was
noted upon palpation of these areas.

Nose

Nose is midline and without abnormalities; septum is midline and without deviations. Mucosa is pink. No abnormal
discharges noted. No maxillary or frontal sinus tenderness noted.

Mouth

Lips appear to be dry and pale in color and without any deformity. No Lesions, cracking, and inflammation were
noted. Tongue and uvula are midline and appears to be slightly red in color. Buccal mucosa is pink, moist and glistening with no
lesion or ulcerations noted. Tonsils are not inflamed.

Neck

No swelling or lesions was noted upon inspection. Neck is flexible and without rigidity. A scar measuring at 3x3 cm was
noted at the left cheek noted. No masses, lymph node enlargement, or tenderness was noted upon palpation.

Thorax and Lungs

No lesions, masses, or abnormal shape noted. Patients has regular and non-labored breathing; symmetrical with bilateral
chest expansion. Retractions and use of accessory muscles were not noted. Chest was resonant upon percussion. Masses and
tenderness were not noted. Normal breath sounds on both lung fields were heard on auscultation.
Cardiovascular

Patient has adynamic precordium and without visible pulsations. No thrills or substernal thrust noted. Point of maximal
impulse was noted at the 4th left intercostal space midclavicular line. Cardiac rate is regular in rate and rhythm; S1 and S2 are
clearly heard at the apex and base; bruits and murmurs were not noted. Pulses are palpable and graded as 2.

Abdomen

Abdomen is protuberant in contour; umbilicus is at midline and inverted; dilated veins, rashes, ecchymoses, and gross
deformities were not noted. Bowel sounds are normoactive at 11 clicks per minute heard over the RLQ. Dullness was noted on the
RUQ; tympany is noted on the LLQ. Spleen and kidneys are not palpable. No costovertebral tenderness or abdominal masses
noted.

Genitourinary and Anorectal

Genitalia is grossly female. Able to defecate and pass out flatus.

Musculoskeletal

No desquamation or scaling was noted. Patient has with complete number of digits, equal and bilateral muscle mass.
Spinal deviation and outpouching, masses, deformities and swellings were not noted. Patient has good muscle tone, and joint
mobility; masses and tenderness were not noted.

Nervous system
Patient is awake, conscious, and dressed clean and appropriately. Patient is irritable. Opens eye spontaneously.

Cranial Nerves:
CN I (Olfactory) able to identify smell
CN II (Optic) able to blink and maintain eye contact.
CN III (Oculomotor), CN IV (Trochlear) and CN VI ( Abducens) - follows when examiner moves side to side
CN V (Trigeminal) Change of facial expression was noted upon touching of the face;
CN VII (Facial) face is symmetric, able to frown and smile and close eyes tighly.
CN VIII (Acoustic) responds when name is called.
CN IX (Glossopharyngeal) and CN X (Vagus) able to feed; intact gag reflex
CN XI (Accessory) symmetrical shoulder musculature
CN XII (Hypoglossal) tongue is at midline

Sensory Response

Extremity Sensory Response

Upper Right 100%

Upper Left 100%

Lower right 100%

Lower Left 100%