Date of Examination: Jan.

23, 2020
General Survey
VS : BP= 120/80mmHg Weight: 52kg
PR=92bpm Height: 5’1
RR=16 breaths/min

SYMMETRY : the patient’s body and face are symmetrical

OLD : patient looks accurately on her age
MENTAL ACUITY : the patient is alert and attentive
EXPRESSION : the patient looks in pain because she is labor
TRUNKS : the patient looks barrel chested
EXTREMETIES : the patient doesn’t have any joint abnormalities or edema
APPEARANCE : the patient is clean and well-dressed
MOVEMENT : her gait and coordination are normal but her movement are very limited
SPEECH : clear and understandable

REVIEW OF SYSTEM PHYSICAL EXAMINATION

SKIN SKIN
 No known skin allergy and disease  The color of the skin varies from light to
deep brown
 With good skin turgor ( goes back in 1-2
seconds)
 No lesions, scars or rashes

HAIR HAIR
 With good and smooth hair  Hair color varies from brown to black
color
 Not oily and dry
 Presence of dandruff

NAILS NAILS
 No nail cracking or breaking  Has a smooth nail texture
 No nail clubbing  Highly vascular nailbed
 Nail shape is concave
HEAD
 “lagi akong nakakaranas ng pagkahilo
tuwing gabi minsan di na ako mapakali”
as verbalized by the patient
 No lumps or mass present
EYES
 With clear vision
 Sometimes the patient experience
diplopia specifically at night
 No redness (sore eyes)
EARS
 No pain
 No ringing or buzzing in the ear
NOSE
 No nasal obstruction
 No history of epistaxis
 No known allergies
MOUTH
 The patient always experience toothache
on both wisdom tooth (lower part) and
one on the left upper part
 No lesions present
 No halitosis
 No dryness
THROAT AND NECK
 With good neck movement; no stiffness
on the neck
 No swelling and lumps on the neck area
 No difficulty swallowing
 No sore throat
RESPIRATORY
 No shortness of breath
 No persistent cough
 No history of respiratory tract infection
HEAD
 The head is rounded and has
symmetrical shape of head
 Has a symmetrical facial features
 No presence of masses or lumps
EYES
 Has reddish conjunctiva
 Sclera is white in color
 Eyebrows and eyes are symmetrically
aligned
 No edema on the lacrimal sacs
 No discharges
EARS
 Symmetrical in positon and shape
 Ears are non-tender
 No ear tags present
 Upper pinna is aligned to outer cantus of
the eyes
 No discharges seen
NOSE
 Nose is centrally located
 Appears symmetrical in shape
 No flaring of alae nase
 No discharges present
MOUTH
 With dry and slightly chapped lips
 With symmetrical lips position
 Tongue and uvula are centrally located
 With presence of dental carries and
cracked teeth
THROAT AND NECK
 Neck are centrally located
 It moves bilaterally without any
resistance ; no stiffness
 No inflammation on the lymph nodes
RESPIRATORY
 No retractions
 With symmetrical chest expansion
 With good voice transmission
  No history of tuberculosis, asthma and  RR= 16 breaths/ min.
pneumonia
 No pain and wheezing when breathing

CARDIOVASCULAR CARDIOVASCULAR
 No chest pain  No edema present
 No palpitation  No murmur
 No cyanosis  No palpitations
 No orthopnea  PR=92bpm
 No edema present on both lower and
upper extremeties
BREAST/CHEST BREAST/CHEST
 No breast pain  With slightly tender breast
 Has history of breastfeeding on previous  Nipples are everted
child (almost 1 year)  With dark areola

GASTROINTESTINAL GASTROINTESTINAL
 Has experience nausea and vomiting  With fair skin color
during pregnancy  Warm to touch on the fundus area
 No indigestion  With smooth skin texture
 With uterine contraction  With presence of Strae Gravidarum
 FHT taken as:  With presence of Linea Nigra
R= 140bpm
L= 143bpm
GENITOURINARY GENITOURINARY
 Has frequent urination  No presence of hemorrhoids
 No burning sensation or pain during
urination
 Has history or urinary tract infection

MUSCULOSKELETAL MUSCULOSKELETAL
 Has back muscle pain due to her  Has limited range of motion or
pregnancy movement
 Patient is steady on her feet  No nodules
 No muscle weakness  No deformities
 No history of any trauma or injury