Arianna Jasmine L.

Mabunga
BSN-2b
12-02-19

Physical Assessment

General Survey

Upon first encounter last November 28, 2019 at 10 am, the patient was sitting on the
chair, awake, coherent, oriented to time, place, person; without an IVF. Upon first taking of the
vital signs, the patient’s weight is 74kg (162.8lbs), the height is 1.52 meters, the temperature
was 35.8 degrees Celcius, the respiratory rate was 18 breaths per minute, the pulse rate was 97
beats per minute, the heart rate was 100 beats per minute, and the blood pressure was
150/90mmhg.

Medical History:

Upon the interview the patient had stated that she had been diagnosed with
Hypertension before she got pregnant and she had been diagnosed with severe pre-eclampsia.
Due to this her doctor opted for her to have a Cesarean delivery last October 31, 2019.

Allergies & Reaction:

Upon interview the patient had verbalized that she had no allergic reaction to any
medication or any food.

Medication:

Upon interview the patient stated that her medicine are at home which are: Lozartan,
Amlodipine, Cefuroxime 500g BID which was taken last 6am, Mefinamic acid 500g as needed
and was last taken at 9pm the previous night, lastly Multivitamins once a day and was taken last
6am.

Skin

Upon inspection, the patient appear to be normal and well nourished with an equal and
fair skin complexion, the patient’s skin was soft and smooth texture; there was no presence of
sores or lesions noted. Upon palpation, patient’s temperature was cool and moist, had no
dryness, no lumps, and no masses on any exposed body part and had a good skin turgor (less
than 2 seconds).

Head

Upon inspection, patient’s head was normocephalic, symmetrical, positioned in the

midline, round and proportional to the body. Upon palpation, patient’s head had no lumps,
masses or deformities, and temporal arterial pulsations are even.

Eyes

Upon inspection, patient’s eyes were symmetrical, conjunctiva was clear and shows
pinkish structure on the lower lids, sclera was white, cornea was clear and smooth upon
passage of light, pupil was black and constricts upon passage of light, had no discharges.

Ears

Upon inspection, patient’s auricles were symmetrically aligned, of equal size bilaterally,
had no missing external features, had a similar color with the skin, had no lesions, thickening or
swelling. Upon palpation, patient’s auricles were soft, smooth and flexible.

Nose

Upon inspection, patient’s nose was symmetric, in mid line, and in proportion to other
facial features; no discharge, flaring or lesions noted. Upon palpation the tip of the nose was
smooth and no tenderness noted.

Mouth and Throat

Upon inspection, patient’s lips were pink and plump, there were no lesions or tenderness
noted, the teeth were slightly yellow with presence cavities and a black plaque on the middle of
the two front teeth, had complete teeth on the upper and the lower part, the oral mucosa is pink
and moist, gums were pink, moist and had no lesions, tongue was positioned medially and is
movable, was pink with a thin white coating and had no lesions, uvula rises and falls upon
humming; tonsils were pink and non enlarged (grade2), and had no lesions; palate were intact,
pink and had no lesions.

Neck

Upon inspection, neck and nape was symmetrical in color and had no lesions, patient is
able to touch the chin to the chest, and turn the head from left to right, motion is smooth and
controlled. Upon palpation, patient’s thyroid gland was not palpable; the lymph nodes are non-
enlarged, movable, discrete, soft and non-tender; carotid artery has an even pulse, and the
throat rises upon swallowing. 

Respiratory:

Upon inspection, the patient manifested quiet and even respiration pattern. Upon
auscultation, the breath sounds were clear and there was no adventitious sound noted. No
secretions were also noted.

Cardiovascular:

The apical pulse is clear and strong with 120 beats per minute, no murmurs, and other
adventitious sounds noted. The left and right radial pulses are both strong and the left and right
pedal pulses are both weak. Pedal pitting edema is also noted grade 2 which disappears with in
10-15 seconds. The oxygen saturation of the patient is 93%.

Gastrointestinal:

Upon inspection, patient’s abdomen is flat, with presence of striae gravidarum and a
transverse surgical scar is present (cesarean). Upon auscultation, there was no bruits, no strong
abdominal aortic pulsations noted; and high pitched gurgling sounds is noted at 25 per minute
(normal bowel sounds).

Upper and Lower Extremities

Upon inspection, patient’s arms were able to flex and extend freely, extremity strength
on the upper right and left are equal, motion is smooth and controlled ; both legs are movable at
equal strength, motion is smooth and controlled; patient is able to ambulate freely without
assistance, Upon palpation, both left and right radial pulses are strong , both left and right pedal
pulses are weak; no joint swelling on the upper and lower extremities, no sign of edema on the
upper and lower extremities.

Genitourinary Assessment

Upon interview the patient had reposted that she had voided last 10:30 am and her Last
Menstrual Period was January 15, 2019. She had also reported that minimal white secretions
are found in her vagina following the bleeding of her delivery.