REVIEW OF SYSTEMS

DURING ADMISSION PRESENT ASSESMENT

GENERAL
no weight loss, no fever, no
chills

current weight unidentified,
no fever, no chills, lethargic,
with right-sided weakness
(hemiplegic)
weight change/fever/sweats/anorexia/
weakness/fatigue/insomnia/others
SKIN
no rashes, no pallor, no
jaundice, no easy
bruisability

with scars on lower
extremities, with pallor on
lower extremities, cold and
clammy skin, poor capillary
reflex, white hair (equally
distributed), presence of
bed sores in the gluteal area
(grade 2), presence of
blisters in the feet,
desquamation in the
inguinal area, clean and
short nails
itchiness/color change/
pigmentation/rash/
vasomotor change/
photo-sensitivity/hair/nails/
moles/others
EYE
no eye discharge, no
pruritus, no pain



visual dysfunction/redness/
itchiness/pain/
scotomata/lacrimation/others
EAR
no tragal tenderness, no
tinnitus, no aural discharge

no deafness, no tragal
tenderness, no tinnitus, no
aural discharge
deafness/tinnitus/discharge/others
NOSE
no colds, no epistaxis, no
nasal discharge

no colds, no epistaxis, no
nasal discharge, with NGT
on left naris
epistaxis/discharge/
obstruction/smell post-op drip/
sinusitis/others
MOUTH
bleeding gums/sores/fissures/
tongue abnormalities/dental caries/others
no toothache, no bleeding
gums, no sores, no fissures
no bleeding gums, no sores,
no fissures, with oral white
secretions (saliva), with
loose tooth on upper left,
have difficulty moving his
tongue, cant eat thru
mouth
THROAT
no tonsillitis, no toothaches,
no gum bleeding, no mouth
sores, no sore throat, no
hoarseness, no dysphagia

no tonsillitis, no gum
bleeding, no mouth sores,
no sore throat, murmuring
of words, cant eat (with
NGT on left naris)
soreness/tonsillitis/others
NECK
stiffness/limitation of motion/
masses adenopathy/sensation/
of lump in the throat/ others
no stiffness, no dysphagia with limitation of motion,
had difficulty turning into
his neck into his right side
PULMONARY
no cough, no sputum, no
dyspnea, no hemoptysis

no cough, no hemoptysis,
with difficulty of breathing,
(+) rhonchi, bilateral
dyspnea/shortness of
breath/cough/sputum/
hemoptysis/wheezing/back pain/
chest wall abnormality/others
CARDIAC
no chest pain, no
palpitations, no paroxysmal
dyspnea (PND), no
orthopnea, no easy
fatigability, no syncope

no chest pain, no
palpitation, no PND, no
orthopnea, no easy
fatigability, no syncope,
hypertensive: 130-140/80-
90
chest pain/ easy
fatigability/nocturnal/dyspnea/
orthopnea/palpitations/syncope/
edema/hypertension/others
VASCULAR
no phlebitis, no varicosities,
no claudication

no phlebitis, no varicosities,
no claudication
phlebitis/varicosities/claudication/
others
GASTRO-INTESTINAL
no abdominal pain, no
vomiting, no diarrhea, no
constipation, no melena, no
hematochezia

no abdominal pain, no
vomiting, no diarrhea, no
melena, no hematochezia,
with constipation
nausea/vomiting/retching/
hematemesis/melena/hematochezia/
dysphagia/belching/indigestion/food
intolerance/flatulence/abdominal
pain/distention/constipation/ anal
lesions/others
GENITO-URINARY
no incontinence, no
urgency, no frequency, no
dysuria, no nocturia, no
flank pain

no incontinence, no
urgency, no frequency, no
dysuria, no nocturia, no
flank pain, with diaper
urinary frequency/urgency/
hesitancy/dysuria/hematuria/nocturia/
urine system flow abnormality/flank
pain/stones/urethral discharge/genital
lesions/testicular mass/perineal pain/
impotence/vaginal discharge/abnormal
bleeding/others
MUSCULOSKELETAL
no muscle pain, no
weakness, no numbness

with muscle weakness
especially on right side
joint stiffness/pain/swelling/muscle
pain/cramps/weakness/wasting/
trauma/abnormal posture/others
ENDOCRINE
no polydipsia, no polyuria,
no heat and cold
intolerance, no hoarseness

no heat and cold tolerance,
diabetic since 2012 (CBG:
156)
heat-cold intolerance/thyroid
problems/voice change/diabetes or
diabetic indicators/neck surgery/or
radiation/others
HEMATOPOIETIC
no bruising, no bleeding
tendencies, no anemia

no bruising, no bleeding
tendencies, no anemia
abnormal bleeding/bruising/
anemia/adenopathy/others
NEUROLOGIC
awake, conscious, GCS 15

lethargic, conscious, GCS 10 headache/seizure/sensory perversion/
motor dysfunction/speech
disturbance/mental changes/head
trauma/others
(E4V5M6) fairly kempt, very
dysarthic, cooperative, with
eye contact, follows
commands
Cerebellum: (-) dysmetria, (-
) dysdiadokinesia

Cranial Nerves:
CN I: not assessed
CN II: pupils 2-3mm ERTL
CN III, IV, VI, EOM full and
equal, (-) diplopia, (-)
nystagmus
CN V1V2V3: intact
CN VII: (+) central facial
palsy, right
CN VIII: intact gross hearing
CN IX, X: tongue protruded
towards the right, (+) gag
reflex
CN XI: can turn head again
resistance
CN XII: shrug shoulder,
weaker right
Motor: 1/5 on RUE and RLE,
5/5 on LUE and LLE
Sensory: no sensory deficit
DTRS: +++ on RUE and RLE,
++ on LUE and LLE
Pathological Reflexes: (+)
Babinski Reflex, right
Meningeal signs: (-) nuchal
rigidity, (-) Kernig sign, (-)
Brudzinski sign
(E4V1M5) very dysarthic,
uncooperative, with no eye
contact, follows some
commands

Cranial Nerves:
CN I: not assessed
CN II: pupils 2-3mm ERTL
CN III, IV, VI, EOM full and
equal on left side, (-)
diplopia, (-) nystagmus
CN V1V2V3: intact
CN VII: (+) central facial
palsy, right
CN VIII: intact gross hearing
CN IX, X: tongue protruded
forward
CN XI: difficulty in turning
the head to the right
CN XII: shrug shoulder,
weaker right
Motor: 1/5 on RUE and RLE,
5/5 on LUE and LLE
Sensory: cant feel light
touch on RUE and RLE
DTRS: +++ on RUE and RLE,
++ on LUE and LLE
Pathological Reflexes: (+)
Babinski Reflex, right
Meningeal signs: not
assessed
PSYCHIATRY
no anxiety, no depression

not assessed anxiety/depression/interpersonal
relationship
difficulties/illusion/delusion/hallucination/
paranoia/others