Lyceum of the Philippines University

College of Nursing

Name R.A. Age

Diagnosis Hospital No.
Ward/RM

CLINICAL APPRAISAL

History of G2P1(1001) upon admission, patient complained of hypogastric pain.

Present Reported last menstrual period on December 21, 2019. Used
Health contraceptives after her first child was born.
Concern

Past Health Her first menstrual cycle(menarche) started when she was thirteen
History years old. Has a regular menstrual cycle. Claimed to have used
contraceptive prior to pregnancy. Was hospitalized three years ago
because she gave birth to her first born. Had pneumonia last October
2019. No history of drug nor substance abuse. Had chicken pox when
she was a child and had an accident by falling off there guava tree
when she was a child. No unknown diseases and allergies to food and
medications. No previous surgeries. Does not recall childhood
immunizations but claims to had completed her immunizations.

Family History Client’s mother (49 years old) with anemia. On the other hand her
father (48 years old) suffers from hypertension, alive. Maternal
grandmother also had ectopic pregnancy and had also undergone
exploratory laparotomy. Maternal grandfather died of complications of
diabetes mellitus. Paternal grandfather died of cardiovascular problem.
Paternal grandmother (73 years old) has hypertension, alive. Client
R.A. has one sibling who is in good health.

Lifestyle and Enjoys going to the mall. Sometimes does household chores. Has
Health someone who prepares her meals. Eats balanced diet. Sleeps around
Practices 4 or 5 in the morning. Wakes up on the afternoon. Stays at home if
there were no important errands. Has an online business. Does
stretching. Regularly uses her phone and watches television as her
past time. Claims to take Paracetamol when migraine attacks. Has a
good relationship with her family, friends, and neighbors. Visits the
 church once or twice a month. But claims to connect with the Lord in
times of trouble. Lives in her own home and claims to have a good
neighborhood.

Lyceum of the Philippines University

College of Nursing

Name Age
Diagnosis Hospital No.
Ward/RM

CLINICAL APPRAISAL

Review of Skin, Hair and Nails: Reports frequent skin bruising but denies
Systems for pruritus. Describes hair as long, dyed and straight. No scalp, lesion or
Current Health flaking. Denies clubbing, pallor and beau lines of nails.
Problem
Head and Neck: Had experienced headaches and sore throats. Denies
neck stiffness, swelling, difficulty swallowing, or enlarged lymph nodes.
Eyes: Wears eyeglasses and contact lenses. Reports blurring of vision
but denies diplopia, itching, excessive tearing, discharge, or trauma to
eyes.

Ears: Reports no ear problems. Denies tinnitus, pain, infections,

discharge or trauma to ears. Does not ask for repetition of questions.

Mouth, throat, nose and sinuses: Reports sore throats. Denies

problem with eating and tasting foods, chewing, swallowing, or sore
tongue. Denies difficulty with smelling, nasal pain, or postnatal drip.
Had experienced rhinorrhea, sneezing and nosebleeds.

Thorax and Lungs: Denies orthopnea, wheezing, or hemoptysis.

Experienced coughs and pneumonia. Reports difficulty of breathing
during third trimester of her first pregnancy.

Breast and Regional Lymph Nodes: Reports breast size enlargement

than usual. Reveals frequent breast pain. Denies lumps, dimpling, and
retraction. Reports no palpated swollen and enlarged lymph nodes
around breasts and axillary region.

Heart and Neck vessels: Denies history of heart palpitation, or edema

but experienced severe chest pain especially on the days prior to
admission.

Peripheral Vascular: Denies claudication, or skin lesions of arms, legs

and feet. Experienced leg bruising, soreness and cramping.

Abdomen: Experienced frequent nausea and vomiting especially

during first trimester of her first pregnancy. Experiences lower
abdominal pain.

Female Genitalia: Denies hematuria, or hesitancy. Had a history of

taking contraceptive pills after birth delivery of her first child. Had her
menarche when she was thirteen years old. Usual flow of menstruation
ranges from three to five days. Had been pregnant twice and undergone
normal spontaneous delivery on her first child. Gone through Exploratory
Laparotomy upon discovery of Ectopic Pregnancy for her second
 conception. Admits pain at the incisional wound region.

Anus, rectum: Reports a daily bowel movement of well-formed stool.

Denies tenesmus, hemorrhoids, hematochezia, or melena. Experienced
constipation and diarrhea.

Musculoskeletal: Denies stiffness, joint pain, or swelling with activity.

Reports lower back pain upon admission.

Developmental
Level