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