PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: ______________

Vital Signs:
Temp: _________ RR: 21 cpm Weight: 83kg
PR: 95 bpm BP: 142/84 mmHg Height: 157cm

Observation: Received pt lying on bed is a 36-year-old Filipino female, G2P1 @ 39 weeks of gestation. Pt is awake, alert and conscious. (+) signs of distress secondary to labor. amniotic fluid was clear.

1. General (weight loss or Received pt lying on bed is a 36-year-old Filipino female, G2P1 @ 39 weeks of gestation. Pt is awake, alert and conscious. PERRLA; Moist Mucous Membranes; heart sounds
gain; fever, chills, night are normal with no murmur; (+) signs of distress secondary to labor. amniotic fluid was clear.
sweats; mood; stage of vital signs as follows: RR: 21 cpm Weight: 83kg
development, race, sex; signs PR: 95 bpm BP: 142/84 mmHg Height: 157cm
of distress; position;
cooperative or not; state if
irritable, agitated or pleasant;
etc.)
2. Head (headache, injury, H - normocephalic and atraumatic, positioned at midline, (-) headache, (-) injury, (-) tenderness;
tenderness, etc.); Eyes E - conjunctiva and extraocular movement are normal, pupils are equal, round and reactive to light, (-) scleral icterus, (-) bilateral periorbital edema, no complaints of visual
(change in visual fields, changes
glasses, blurring, diplopia, E - symmetrical, (-) lesions in the are and no hearing problem, (-) no redness, swelling or thickening
pain, loss of vision, tearing, N - symmetric in the midline, (-) obstruction, inflammation and discharges;
dry eyes, etc.); Ears (change T - patent and moist, (-) irritation in the area and swelling, (-) thyroid gland or lymph node enlargement
in hearing, tinnitus, discharge,
dizziness, etc.); Nose
(allergies, sinus problem,
obstruction, polyps, sneezing,
epistaxis, etc.);Throat
(toothaches, loose teeth,
bleeding gums, mouth sores,
hoarseness, difficulty
swallowing, etc.)
3. Integumentary System Fair skin pigmentation and equal distribution of hair throughout the body, skin is dry and normothermic when touched, (-) edema, normal pulses in all four extremities when
noted and palpated

4. Respiratory System (-) chest pain, pressure, tightness, palpitations, respiratory rate @ 21 cpm; (-) respiratory distress, (-) tachypnea, (-) wheezing, (-)
(chest pain, dyspnea, cough,
amount and color of sputum,
hemoptysis, etc.)

5.Cardiovascular System
Patient’s Name / Room No. | 1
(chest pain/ pressure/ (-) chest pain, pressure, tightness, palpitations; heart sound was normally heard c normal rate @ 95bpm regular rhythm with no murmur, (-) edema, (-0 claudication, (-)
tightness, palpitations, endurance
orthopnea, paroxysmal
nocturnal dyspnea, shortness
of breath, edema, claudication,
endurance, etc.)
6. Digestive System Moist mucous membranes, abdomen is soft, (-) distension, (-) tenderness (-) abdominal pain; normal bowel sounds upon auscultation, no changes noted. No signs of GERD are
(dysphagia, heartburn, ulcer, noted; (-) indigestion, ulcer, diarrhea, constipation; (-) blood in stool, black tarry stools, reduced calibre in stools; (-) hemorrhoids.
GERD, indigestion, food
intolerance, diarrhea,
constipation, abdominal pain,
blood in stool, black tarry
stools, changes in bowel
habits, reduced caliber of
stools, hemorrhoids, etc.)
7. Excretory System (-) urgency, frequency; (-) nocturia, dysuria; (-) hematuria, pain upon urination; no signs and symptoms of recurrent infection, UTI.
(urgency, frequency, nocturia,
dysuria, hematuria, recurrent
UTIs, STD, incontinence, etc.)
8.Musculoskeletal System (-) Limitation of movement; (-) stiffness and joint pain; (-) swelling or redness; (-) arthritis; (-) muscle spasm and muscle weakness
(limitation in movement,
stiffness, joint pain, swelling
or redness, arthritis, muscle
spasms, muscle weakness,
etc.)
9. Nervous System Pt is alert, awake, oriented to self, time, place and events

10. Endocrine System (-) heat/cold intolerance; hair is evenly distributed; skin is light warm to touch; lymph nodes not palpable; (-) thyroid gland enlargement; (-) polydipsia, polyuria, and
(heat/cold intolerance, weight polyhagia.
change, fatigue, polydipsia,
polyuria, polyphagia, changes
in hair distribution, etc.)
11. Reproductive System 36 years old female. G2P1 @ 39 weeks of gestation

Patient’s Name / Room No. | 2