A.

PHYSICAL ASSESSMENT

General Appearance

 Patient is seen with normal skin color – brown. Has normal breathing and speak calmly. No
significant findings noted.
 Patient is 23 years old and pregnant, stands 5’2 with a weight of 60 kg.

Mental Status

 She is alert and coherent upon interaction and answer questions conveniently.

Integumentary

 The patient is fair in color and with good capillary refill both lower and upper extremities.

Head, Face and Neck

 Upon inspection, the skull is generally round, with prominences in the frontal and occipital area.
(Normocephalic) no tenderness.
 The scalp is lighter in color than the complexion. Can be moist or oily. No scars noted. Free from
lice, nits, and dandruff. No lesions should be noted.
 The hair is black in slight brown. Evenly distributed covers the whole scalp. No evidence of
Alopecia. Maybe thick or thin, coarse or smooth. Neither brittle nor dry. The shape is slightly
oval.
 Face is symmetrical. No involuntary muscle movements. Can move facial muscles at will. Intact
cranial nerve V and VII.
 The neck is straight. No visible mass or lumps and it’s symmetrical.

Eyes and Vision

 The eyes are evenly placed and in line with each other. None protruding. Equal palpebral fissure.
 The eyebrows were black and are symmetrical and in line with each other and evenly
distributed.
 The eyelashes were black in color and evenly distributed. Turned outward.
 For the upper eyelids, it covers the small portion of the iris, cornea, and sclera when eyes are
open. No PTOSIS noted. (Drooping of upper eyelids). Meets completely when eyes are closed.
And is symmetrical.
  For the both conjunctivae it is pinkish red in color. Moist, no ulcers, and no foreign objects.
 The sclera is white in color (anicteric sclera), no yellowish discoloration (icteric sclera). Some
capillaries may be visible.
 For the cornea, no irregularities on the surface. Looks smooth.
 The cornea is clear or transparent. There is a positive corneal reflex.
 The anterior chamber is transparent. No noted any visible materials.
 From the side view, the iris appears flat and not bulging forward.
 For the pupils, pupillary size ranges from 3 – 7 mm, and are equal in size and is equally round.

Ears and Hearing

 For the ears, the earlobes are bean-shaped, parallel, and symmetrical.
 Skin is the same in color as in the complexion. No lesions noted on inspection. No discharges or
lesions noted at the ear canal.

Nose and Sinus

 For the paranasal sinuses, nose in the midline. No discharges, no flaring alae nasi.
 Both nares are patent and nasal septum in the midline and not perforated.

Mouth and Pharynx

 The mouth and oropharynx lips is symmetrical in appearance and movement and no signs of
edema.
 For the temporomandibular, it moves smoothly and no crepitus.
 The teeth is white to yellowish in color. No malocclusions.
 The tongue is pinkish with white taste buds on the surface. No lesions noted. Gag reflex is
present.

Lungs and Thorax

 Both left and right chest of posterior thorax is symmetrical. The spine is aligned and has no
evidence of scoliosis. No chest abnormalities noted.
 The height of shoulders and hips is within the normal range.

Heart

 No significant findings noted.

Abdomen

 For the abdomen skin color, it is uniform and has no signs of lesions.
 For the breast, it is symmetrical at rest.
 No significant findings noted.

Extremities

 There are no involuntary movements or both of the upper and lower extremities. No
deformities, bruises, and edema present upon inspection.
 Has equal contraction and even.
 Can perform complete range of motion and both upper and lower extremities are equal in size.