LORMA COLLEGES CON TEMPLATE

PHYSICAL EXAMINATION
RELATED LEARINIG EXPERIENCE

STUDENT NAME: COLLADO, Krizzia Mae C. ROTATION: 3rd rotation AREA: Hospital
YR LEVEL AND SEC: BSN II- Faye Abdellah DATES: April 15, 16, 17, 22, 23, 24, 29 CLINICAL INSTRUCTOR: Mrs. Guerly Acosta

A. GENERAL ASSESSMENT
 The patient stand 4’8 and weighs 45 kgs; physically small, pale in appearance; verbalized extreme fatigability an dizziness occurring at times.
 V/S: T- 37. 2C, RR 19, PR- 100, O2 Sat 96%, BP 150/89, FHT is 155 bpm.

B. SKIN, HAIR, AND NAILS

 Pallor with evenly colored skin tone; no presence of lesion; skin is intact; skin turgor is good; striae gravidarum is present.
 Hair color is natural, silky and smooth; strands are evenly distributed; no presence of nodules and lesions; no unusual odor; no presence of infestation.
 Nails are clean and trimmed; round shape nails; color is pinkish; capillary refill is 2 sec.

C. HEAD AND NECK

 Head shape is generally round; No presence of lesion; no presence of bulging lumps.
 Neck is in normal position; neck is symmetrical; no presence of lumps and masses.

D. EYES AND EARS

 Distant visual acuity is 20/20; near visual acuity is 14/14 without corrective lenses.
 No presence of nodules in ears; able to hear clearly and comprehend what is being said.

E. MOUTH, THROAT, NOSE, AND SINUSES

 Lips are pinkish; no presence of lesion; gums are pink; tongue is moist and saliva is present; pink and even.
 The color of tonsils is pink; no foul odor.
 Nose has no presence of lesion; no presence of inflammation.
 No presence of tenderness in sinuses.

F. HEART AND NECK VESSELS

  Normal and regular pulse rate.
 FHT is normal and regular.
 No presence of lesion, no presence of nodules.

G. ABDOMINAL ASSESSMENT
 Contraction characterized as painless irregular to regular contraction occurring more than 30 seconds throughout the day.
 No presence of lesions; stretch mark is present.
 Fetuses are in cephalic presentation.
 No presence of an enlarged organ.

H. EXTREMITIES
 Extremities size and length are symmetrical; no presence of bone deformities.
 Normal ROM; no involuntary movements.
 No presences of fraction and dislocations.

J. GENITALIA
 The labia minora and mojora are symmetrical and slightly pigmented; no presence of lesion, swelling and nodule.
 Trimmed pubic hair; no presence of infection; urethral meatus were slit like and were located at the midline.

I. NEUROLOGIC
 The patient were moderately uncomfortable due to the contractions and high-risk of pregnancy.
 The patient’s cranial nerves, muscle movement, balance, coordination as well as all the reflexes were all normal.
 The patient feel immense worry due to their insufficient financial ability.