Davao Doctors College, Inc.

General Malvar St., Davao City

Nursing Program

2
ASSESS THE PATIENT (Initial/Focus/General): Use BLUE
for normal findings and RED for ABNORMAL FINDINGS.

General Patient had no fever, (+) for excessive weight gain

started @2nd trimester of pregnancy. Patient is
awake, alert not in respiratory distress, not in pain.
Skin Fair complexion, no rashes, and no jaundice.
Presence of Strae gravidarum, Linea negra on the
abdomen and chloasma is visible on face. Negative
for bruisability.
Head, Eyes, Head: Head is normocephalic. Has headache
Eyes: Anicteric sclera, pink palpebral conjunctiva,
Ears, Nose,
puffy eyelids. No eye discharge.
Throat Ears: No ears discharge.
Nose: No nose discharge. Nasal septum in midline.
Throat: tonsils Nonhyperemic, non hypertrophic
Mouth & Pharynx: Dry lips. Moist oral mucosa

Neck No cervical lymphadenopathy

Breast Breasts are symmetric, no dimpling and

discoloration noted, nipples and areolas are dark in
color

Respiratory No dyspnea was noted, no cough and colds.

Orthopnia, palpitations and chest pain was not noted.

Cardiovascular Orthopnia, palpitations and chest pain was not noted.

Equally chest expansion. Heart has a dynamic
precordium, normal rate and regular rhythm. With
clear breath sounds.
Gastrointestinal Has nausea. Abdomen is globular. Has a soft tender
abdomen. Abdomen had audible bowel sounds.
Urinary No dysuria, hematuria and frequency urgency.

Genital Fundic Height: 23 cms. Experiences painless vaginal

bleeding and cramping.
Peripheral/Vascular Capillary refill actively returns to its normal color
in less than 2 seconds.

Musculoskeletal Extremities have a good range of

motion .Varicosities and edema was noted on
lower extremities. No pathological reflexes
noted
Neurologic Memory is intact. Level of consciousness of the
patient patient has a GCS of 15. No seizure
Hematologic Blood type: AB (+)

Endocrine No heat and cold intolerance

Psychiatric (no indication)

Name of Student: _SHERYL ANNE D. GONZAGA____