SAMPLE ROS AND PE

SYSTEM R.O.S. P.E.

1. General  awake, conscious and
“…Bumigat ang timbang coherent
ko.”  ambulatory with minimal
assistance
 with good muscle strength
 T= 36.7°C
 PR=75 bpm, regular and
equal in strength
bilaterally
 RR=23 cpm, regular and
spontaneous
 BP=120/80 mmHg
 Wt=70 kg

2. Integument
 “Madami akong Skin:
mapupulang butlig sa  (+) maculopapular rashes
likod” on L scapular area, about
2-3mm in diameter
 “…Buhok ko, maputi na,  dry, scaly skin on both
tumatanda na kasi” upper and lower
extremities
 (-) hyperpigmentation
 good skin turgor
 warm to touch
Hair:
 normal hair distribution
 black with some gray, fine
hair; no parasites evident
Nails:
 round, hard, nails with
pink nail beds
 capillary refill <3 seconds
3. Head
 “Dati malimit sumakit  symmetrical, smooth, firm
ang ulo ko pero ngayon  (-) lesions on the scalp
hindi na.”  normocephalic
 temporomandibular joint
felt bilaterally with full
ROM
4. Eyes
 Malinaw pa naman ang  symmetrical blinking
paningin ko.”  bulbar conjunctiva clear
with tiny vessels visible
 “My katarata rin ako”  round and equal iris
 (+) opacity of the left lens
 “… Huling check-up ko  PERRLA
sa mata noong January  passed accommodation,
03, 2010” extra ocular and cover
test
 nontender lacrimal
apparatus
5. Ears
 “Hindi naman masakit  (-) discharges on external
ang tainga ko, makati ear
lang.”  passed whisper and
Romberg test
 “…Cotton buds ang  (-) tenderness
ginagamit ko kapag
naglilinis ng tainga”

6. Nose and Sinuses  (-) nasal discharges

 pink and moist mucosa
 “Bihira lang akong with no lesions
magkasipon.”  (-) lesions in turbinates
and septum
 (-) nasal flaring
 (-) nontender nasal
sinuses
 sinuses clear upon
illumination
7. Mouth and Throat
“Wala naman akong  (-) hoarseness
problema sa lalamunan.”  dry lips
 (+) gag reflex
 no upper central incisors
 (-) lesions on lips, mouth
and throat
 pharyngeal tonsils not
inflamed
8. Neck
 “Hindi naman masakit  (+)full ROM
kapag ginagalaw.”  smooth, firm and non-
tender thyroid
 “Kulani, wala naman…  (-)cervical lymph node
masakit lang kapag enlargements
dinidiinan”
9. Breast and Axilla
“Wala namang masakit, sa  (-) dimpling, discoloration,
dibdib ko.” tenderness, nipple
discharges
 flat, pale brown areola
 nipples everted
 (-) axillary lymph nodes
enlargement

10. Respiratory
 “Inuubo ako.”  (+) cough productive of
yellowish phlegm
 “Nagka - pneumonia na  shallow, fast breathing
ata ako pero dati pa.”  symmetrical thoracic
expansion
 (+)rales on both lung
fields
 (-) crepitus
 (-) wheezing

11. Cardiac
“Nahihirapan akong  (+) apical pulse felt at 5th
huminga kapag nakahiga.” ICS LMC line
 identical apical and radial
pulse @ 75bpm,
 normal heart sounds
 regular rate, normal
rhythm

12. Gastrointestinal
 “Hindi naman ako  round, flabby abdomen
nahihirapang kumain,  (+) keloid on Mc Burney’s
malakas nga akong area
kumain ng matataba dati  (-) rashes
eh”  normoactive bowel sounds
@ 6 BS per minute
 “Isang beses ako kung  (+)tympany in all 4
dumumi sa isang araw, quadrant
kalimitan sa umaga.”  normal liver span
 no enlarged organs
 “Natanggal na ang  (-) mass
appendix ko, 10 years  (-) tenderness
ago.”
13. Urinary
 “Hindi naman masakit  urine output of >30mL/hr
kapag umiihi ako”  urine color: amber yellow
 (-) bladder distention
 “Mga sampung beses sa  normal kidney punch test
isang araw ako kung
umihi dati pero ngayon
walo na lang… kapag
nasa ospital dalawa
hanggang tatlong beses
lang… Minsan naiihi na
rin ako sa shorts,
mahirap kasi lumakad.”
14. Genitalia
“Malapit na yata akong mag
menopause.”  no lesions, inflammation,
nor discharge
abnormalities noted

15. Peripheral “Ayan, ang lalaki ng mga  (+) varicosities on both

Vascular ugat ko sa binti dahil lower extremities
malimit akong nakatayo sa  (-) jaundice or any
trabaho ko dati.” discoloration
 (-)Homan’s sign
 capillary refilll < 3 seconds
 bilateral radial pulses
strong and equal @ 75bpm
 bilateral pedal pulses
regular and equal at 71
bpm

16. Musculoskeletal
“Mahirap maglakad,  with slight kyphosis
kailangan ko pa ng tulong  unsteady gait
baka kasi matumba ako…  (+) full ROM and muscle
Kahit nga pumunta lang ng strength of upper
CR mahirap na eh.”  (+) muscle spasm on right
leg

17. Neurologic
“Na - stroke na ako dati,  responds to questions
noong 1995 ata yun, matagal and statements
na eh.” appropriately
 oriented to time, place,
and person
 CN I: able to smell odor
correctly
 CN II: Snellen chart result
: 20/20
 CN III,IV, VI: good EOM
 CN V: (+) sensation to
light touch and pain
 CN VII: (-) drooping of the
corner of the mouth while
head was still; able to
raise eyebrows, wrinkle
forehead, clench teeth,
puff out cheeks
 CN VIII: passed whisper
and Romberg test
 CN IX: (+) gag reflex, able
to identify taste
 CN X: (+)symmetrical
elevation of palate, uvula
rises while swallowing
 CN XI: (-) able to shrug
shoulders, able to move
neck with ease
 CN XII: (-) limitation of
tongue movements
18. Hematologic
“Alam ko, hindi ako  (-) bleeding
anemic.”  (-) bruising

19. Endocrine “Madalas akong  (+)excessive sweating,

pagpawisan” especially on both axillary
area
 (+) heat and cold
tolerance
20. Psychiatric
“Minsan parang nagiging
NO P.E.
makakalimutin ako.”