Republic of the Philippines

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
Intramuros, Manila

College of Nursing

DIRECTION:

1. Obtain client History and Initial Interview of a pregnant client. (e.g., referred by friends, pregnant mother you personally know such as
relative).
2. Accomplish the initial antepartum form provided in doing your online interview, rationalize each and every step. (Refer to the format
below). Each rationale should be supported with references (APA format)
3. The document shall be turned over through LMS, a specified time will be allotted by your professor.

QUESTIONS CLIENT RESPONSE INTERPRETATION RATIONALE

1. Demographic Data a) Name (Initials only) - J.  Patient JT is a 35- year-  Collecting the demographic data is very
a) Name (Initials only) T. old pregnant woman important because it helps in the
b) Age b) Age - 35 years old born on April 1987, she registration process of the patient. It also
c) Ethnicity c) Ethnicity - Filipino is currently residing at helps us nurses and healthcare providers
d) Height d) Height - 5’4” Bacoor, Cavite, with 5 to effectively establish trust and rapport
e) Weight (actual e) Weight (before feet and 4 inches of to the patient and at the same time
when not pregnancy) - 58 kgs height. She weighed 58 understand the patient's background.
pregnant) f) Weight (during kilograms before her Reference: Albany Edu. (2020). Why
f) Weight (when pregnancy) - 55.90 kgs second pregnancy but Hospitals Should Collect Demographic
pregnant) g) Blood Type - O+ now that she’s carrying Data? Retrieved from
g) Blood Type h) Address - Bacoor, Cavite a baby, she’s already https://www.albany
i) Birthday – April 1987 55 kilograms. As I .edu/cphce/mrt_to ols/staff_tools/Englis
asked her about her h/Justification%20fo r%20frontline
blood type, she told me %20staf f%20FINAL.pdf
 that she is Blood Type
O+. PhilHealth is her
healthcare insurance
provider.
 Pregnancy is a state where women gain
weight due to many changes in their daily
routine and of course to provide proper
nutrition to the growing fetus.
Women gain more weight in the final
months of pregnancy than they do in the
first few months. This isn't only due to
the weight of the growing baby. Much of
the weight gained is extra fluid (water) in
the body.
Reference: Adegboy, R. (2018, March
22). Pregnancy and birth: Weight gain
in pregnancy. Retrieved from
https://www.ncbi.nl m.nih.gov/books/N
BK279575/

2. Chief Complaint a. August 1, 2022  The current pregnancy • Morning sickness is also known as nausea
a) When was your last b. “Marami. Medyo of patient J. T., which is gravidarum, nausea/vomiting of
menstruation? matindi ang pagsusuka her second pregnancy, pregnancy (NVP), emesis gravidarum, and
b) How do you feel at sumasama ang is a planned pregnancy. pregnancy sickness. For many women,
about being pakiramdam. (A lot. The  The patient the symptoms of morning sickness are
pregnant? vomiting is quite severe experienced severe their first signs of pregnancy.
c) What are your and the feeling vomiting and felt weak • As a normal part of pregnancy, your
signs of early worsens.).” most of the time. Also, breathing may be affected by the
pregnancy? c. “Fatigue, sore breast, according to the client, increase in the hormone progesterone,
d) How is your missed period (delayed fatigue and sore which causes you to breathe in more
pregnancy going? for 2 days).” breasts were felt as deeply. This might make you feel as if
Are you d. “Currently umiinom ng early signs of you're working harder to get air.
experiencing any gamot sa pagsusuka at pregnancy. The client Breathing may also become more difficult
discomfort? pagkahilo. Hindi missed her period for 2 as your enlarging uterus takes up more
When? makagalaw masyado days as her last period space, resulting in pressure against your
e) How many times due to bedrest. was on August 1, 2022. diaphragm (the muscle below your
have you seen a (Currently taking  Last October 1, 2022, lungs). Reference: Joseph,E. (2016,
medical provider medicine for vomiting on the patient’s 2nd October). Why Do Some Pregnant
 for prenatal check- and dizziness. Can't month of pregnancy, Women Have Trouble Breathing?
up? move much due to patient J. T. underwent Retrieved from https://kidshealth.or
f) If you had an bedrest.)” transvaginal g/en/parents/breat hing.html
appointment with e. “First time last Saturday ultrasound. A small • Nausicare Tablet is a combination
a medical provider, (October 1, 2022)”. subchorionic medicine used to treat nausea and
has your medical f. “Recently underwent hemorrhage was seen vomiting during pregnancy. It prevents
provider told you transvaginal ultrasound. on her uterus that the feeling of nausea and sickness in
about any health or May nakita na maliit na needed to be treated pregnant women. It also provides
medical concerns subchorionic immediately. nutrition to the body. Reference:
with your current hemorrhage na need  Changes in behavior https://www.1mg.com/drugs/nausicare-
pregnancy, such as magamot immediately. was also observed by tablet-398003
high blood (Recently underwent patient J. T. Starting • Duphaston 10mg Tablet 10's is used to
pressure, transvaginal ultrasound. from her diet. Due to regulate the uterine lining in
gestational A small subchorionic vomiting often, her postmenopausal women receiving
diabetes, or hemorrhage was found appetite decreased. estrogens who have not removed their
pregnant with two that needs to be treated  patient J. T. is currently uterus through surgery. It also helps treat
or more babies? immediately.)” taking Folic acid for the amenorrhea (cessation or irregular
g) Have you had any g. “Magana kumain noon baby, Nausicare for her menses cycle for more than three
changes in your but now due to nausea every morning months) Reference:
habits or behavior? pagsusuka ay hindi na due to morning https://www.apollopharmacy.in/medicin
h) Were you exposed makakain. (I used to eat sickness, and e/duphaston-10mg-tablet
to any contagious well but now due to Duphaston to prevent • Folic acid is the synthetic form of folate,
disease? What? vomiting I can't eat a lot miscarriages. The said which is a naturally occurring B vitamin.
When? How? anymore.) medicines are not Folate helps make DNA and other genetic
i) Do you have any h. “Hindi naman” harmful for the fetus. material. It is especially important in
diseases during i. “Wala naman”  The patient was not prenatal health.
pregnancy? j. “Folic acid for baby exposed to any Reference: MediLexicon International.
j) Are you taking any (once a day), Nausicare contagious diseases. (n.d.). Folic acid: Importance,
medications for Nausea (2x a day, deficiencies, and side effects. Medical
(prescribed? every morning and after News Today. Retrieved October 5, 2022,
vitamins, home meal), and Duphaston from
remedies?) (What para sa pampakapit sa https://www.medicalnewstoday.com/arti
and how often do baby (2x a day, every 12 cles/219853
you take them?) hours)”
 k) Has taken any k. “Wala naman”
medication that l. Planned
might be harmful
to the fetus?
l) Is your pregnancy
planned or
unplanned? (What
are your concerns
or plans?)

3. Family profile  Patient J. T. is currently Socioeconomic Status affects outcomes in

a) Marital Status a) Married living with her husband different ways. In fact, SES is considered by some
b) Family b) Family of 3 and only son in a 2- to be the most important influence on morbidity
Composition/Type c) College Graduate storey house. With and mortality (Adler & Snibbe, 2003). Firstly,
of Family d) Housewife both of them as her those of lower SES have less access to health care
c) Educational e) Living in a 2-storey support system. Client (APA, 2007). Those of higher SES have access to
Attainment house J. T. and her husband more health knowledge, better housing and
d) Occupation f) College Graduate are married to each nutrition, and better health care (Adler & Snibbe,
e) House Structure g) Working at the other. 2003).
f) Partner’s government  She is a college Reference: Adler, N. (2015, September).
Educational h) “Yung asawa at anak ko” graduate and is now Why socioeconomic status (SES) matters.
Attainment currently a housewife. Retrieved from https://www.apa.or
g) Occupation  Her husband is also a g/pi/ses/resources/i ndicator/2015/09/so
h) Support System college graduate and is cioeconomic-status
working at the
givernment.
4. Past medical History • Cesarean section is done when vaginal
a) Do you have any a. “Wala naman” • The patient doesn’t birth or delivery can be risky.
health problems b. “Wala naman” have any health Reference: Marchof Dimes. (2018,
before pregnancy? c. “Allergic rhinitis” problems before October). Medical Reasons for a C
b) How about d. “Cesarean delivery”. pregnancy, no Section. Retrieved from
childhood e. “Multivitamin” childhood diseases, no https://www.march ofdimes.org/pregna
diseases? Is it still allergies, and she has ncy/c-section- medical-reasons.aspx
occurring or is it undergone surgical
 already treated? procedures or cesarean
c) Allergies? Drug delivery • As nurses, we need to document the past
sensitivities? medical history of the patient for us to be
d) Went through any aware of what problem will arise. Some
surgical medical conditions may worsen during
procedures? What? pregnancy and/or have complications for
When and where? the developing fetus. Those who have
e) Any medications? undergone surgeries may affect their
decision regarding delivery due to the
presence of scar tissues and adhesion.
Reference: Potter, L. (2020, October 19).
Obstetric History Taking. Retrieved from
https://geekymedics.com/obstetric-
history-taking/

5. Family History  Upon interviewing the • If either of you have a family health
a) Do you have any a) “Sa mother side ko ay patient, she mentioned history of a birth defect, developmental
familial diseases? may history ng cancer” that on her mother's disability, newborn screening disorder, or
(Mother and father b) “Wala naman” side, there is a history genetic disease, your baby might be more
side) c) “Wala naman” of cancer. likely to have this condition. Knowing if
b) Do you have any d) “Wala naman”  On her spouse’s side, your baby is more likely to have one of
relatives that have e) “Healthy naman silang there is a history of these conditions is important so that you
special needs or lahat” diabetes and heart can find and address potential health
are mentally f) “Yung family ng partner conditions. problems early.
challenged? ko ay may history sila ng  There are no genetic Reference: Center for Disease Control
c) Any blood diabetes and heart and inherited diseases, and Prevention. (2019, October 3). Family
disorders? condition” blood disorders, and Health Pregnancy. Retrieved from History
d) Any genetic or relatives who are During
inherited disease? mentally challenged. https://www.cdc.gov/genomics/famhisto
e) What is the current  Patient J. T. is healthy ry/famhist_during_pregnancy.htm
health status of and has no underlying • Rh antibodies are harmless until the
your family health issues as well as mother's second or later pregnancies. If
members (parents the people she lives she is ever carrying another Rh-positive
and siblings)? with (husband and child, her Rh antibodies will recognize the
 f) Partner’s health son). Rh proteins on the surface of the baby's
history (genetic blood cells as foreign. Her antibodies will
disorder, chronic pass into the baby's bloodstream and
disease or attack those cells. This can make the
infection, baby's red blood cells swell and rupture.
substance use and This is known as hemolytic or Rh disease
abuse, blood type of the newborn. It can make a baby's
and Rh blood count get very low.
compatibility) Reference: Fuentes, A. (2018, October).
Rh Incompatibility During Pregnancy.
Retrieved from https://kidshealth.or
g/en/parents/rh.ht ml
7. Gynecologic History
a) Menarche a) 14 years old (2001)  Patient J. T. • Regular menstrual periods tell you that
b) Menstrual b) Regular every month experienced menarche your hormones are in balance — critical
regularity c) August 1, 2022 when she was 14 years when you realize about 80% of the
c) Last menstrual d) 6-7 days old in the year 2001. women, I see in my practice today
period e) “Oo, Cesarean Her menstruation experience symptoms relating to
d) Length of delivery” starting from her hormonal imbalance. If not addressed, it
menstrual period f) “Hindi” menarche until now is can lead to worsening PMS, fatigue and
e) Did you undergo g) “Oo” regular (every month) weight gain, as well as increased risk for
any past or present h) N/A that lasts up to 6-7 more serious health issues.
surgical procedures i) 1 days. Reference: Arora, S. (2020). Health
(reproductive j) Yes  Her last menstruation benefits of regular menstrual periods.
organs)? k) Different Gender was on August 1, 2022. Retrieved from https://www.wome
f) Are you practicing (Male)  The client preferred nshealthnetwork.co m/pms-and-
family planning? l) “Hindi” not to answer the menstruation/healt h-benefits-regular-
g) Are you sexually m) “Hindi” question asking about periods.aspx
active? n) “Wala naman” her first sexual • Determining gestational age is one of the
h) When was your o) “Hindi, Wala naman” intercourse. most critical aspects of providing quality
first sexual  Patient J. T. is sexually prenatal care. Knowing the gestational
intercourse? active. For the past age allows the obstetrician to provide
i) How many sexual months, her only care to the mother without
partners have you sexual partner has compromising maternal or fetal status.
 had in the past six been her husband. Reference: Edwards, K. (2020, August 16).
months? They had no Estimated Date of Delivery. Retrieved
j) Are you satisfied complications during from https://www.ncbi.nl
with your current sex. Her partner is m.nih.gov/books/N BK536986/
sex life? male. • Use of contraception prevents
k) Is your sexual  The patient is not pregnancy-related health risks for
partner of the taking any women, especially for adolescent girls,
same or different contraceptives and and when births are separated by less
gender? birth control. She also than two years, the infant mortality rate
l) Are you using mentioned that she is 45% higher than it is when births are 2-
contraceptives or and her husband are 3 years and 60% higher than it is when
any birth control not currently practicing births are four or more years apart.
methods? family planning. Reference: World Health Organization.
m) Have you ever  There is no sexual (2020, June 22). Family
contacted contact with a person planning/contrace ption methods.
someone with who has sexually Retrieved from https://www.who.int
sexually transmitted diseases. /news-room/fact- sheets/detail/family
transmitted  She also stated that -planning- contraception
infection or disease she doesn’t have • STI during pregnancy can pose serious
(HIV-AIDS, Syphilis, vaccine against Human health risks for you and your baby. As a
etc.)? Papillomavirus. result, screening for STIs, such as human
n) Have you had a immunodeficiency virus (HIV), hepatitis B,
vaccine against chlamydia and syphilis, generally takes
Human place at the first prenatal visit for all
papillomavirus? pregnant women.
o) Are you having Reference: Mayo Clinic. (2020, January
problems during 9). Pregnancy week by week. Retrieved
sex? from https://www.mayoc
linic.org/healthy- lifestyle/pregnancy-
week-by-week/in- depth/stds-and-
pregnancy/art- 20115106

• Human Papilloma Virus (HPV) has over

150 serotypes and can cause human
 infections in the squamous epithelium of
skin and mucous membranes. Most
conditions caused by HPV are
asymptomatic, but some low-risk
genotypes can cause papillomata, while
high-risk genotypes can cause dysplasia
and cancer of the anus, vulva, vagina and
cervix.
Reference: Barbaro, B. (2016, August). Is
HPV vaccination in pregnancy safe?
Retrieved from https://www.ncbi.nl
m.nih.gov/pmc/arti cles/PMC4994723/

8. Obstetric History  Patient J. T. is currently

(GPTPALM) a) “2nd pregnancy ko na on her second • Obstetric scoring has been proposed as a
a) History of previous ito, yung una dineliver pregnancy at 8 weeks tool to reduce maternal and child
pregnancy ko siya after 40 weeks”  The obstetric scoring of complications. It also gives data that is
• More than 37 b) 8 weeks na yung baby the patient J. T. is G2T1 essential for pregnancy.
weeks, premature sa tiyan ko ngayon”. (11010). Gravida 2, • Pregnancy is usually a time of
stillbirth, c) G2P1 (11010) Para 1 with one child excitement. But sometimes, pregnant
miscarriage, d) Caesarean Delivery delivered after 40 women and their partners may feel like
abortion, alive, e) “1 trimester once a
st weeks, no premature they're expecting a bundle of anxiety
multiple month, 2nd twice a birth, no record of along with the joy. They have a long list
pregnancy) abortion and of to-dos. They have to cope with the
month, 3 madalas”.
rd

b) History of present miscarriages, one child changes and unknowns that come with
f) “Noong sa unang anak
pregnancy living, and has no pregnancy and birth.
ko naramdaman ko yung
c) GPTPALM record of multiple Reference: Husney, A. (2019, May 29).
excitement na
(obstetric scoring) pregnancy. Partner Support During Pregnancy.
magkakaanak na ako
d) Normal delivery or  The first delivery was Retrieved from https://www.mottch
noong first trimester,
caesarean cesarean. However, the ildren.org/health- library/abp7352
nagchange ako ng diet
e) Any maternal and birth delivery for the • Adequate nutrition during infancy and
and lifestyle, and taking
child second pregnancy is early childhood is essential to ensure the
precautions. Sa second
complications? still unknown. growth, health, and development of
trimester naman noong
How’s the last  Patient J. T. children to their full potential. Poor
unang pagbubuntis ko
 check-up? pinangako ko na dapat
f) What is your alagaan ko si baby.
maternal Iiwasan ko lahat ng
psychological makakasama sa
adaptation to pagbubuntis ko then
pregnancy? ingat sa kinakain at
• 1st trimester (focus bigyan ng magandang
on self) buhay, like Vitamin
• 2nd trimester intake, and more check-
(focus on the baby) ups. Sa third trimester
• 3rd trimester naman ng unang
(focus on pagbubuntis ko,
parenting) siyempre sinabi ko na
g) What are your kailangan kong maging
methods of feeding mabuting ina sa kanya,
an infant? guide siya sa lahat and
and Preparations ng
things and papers sa
hospital like name ng
baby. Masaya ako dahil
lahat naman planado
kahit itong pangalawa
ko. Wala akong
naramdaman na kahit
anong lungkot o
pagkabalisa simula  For the client’s first
nagkaroon ako ng
baby.”
g) “2 months
breastfeeding and the
rest is formula (bottle
feeding)”
psychological nutrition increases the risk of illness, and
adaptation to is responsible, directly or indirectly, for
pregnancy focuses on one third of the estimated 9.5 million
preapring to be a god deaths that occurred in 2006 in children
mother to her first less than 5 years of age.
child. At her first Reference: World Health Organization.
trimester, she started (2009). The importance of infant and
changing her diet and young child feeding and
lifestyle, taking recommended practices. Retrieved
vitamins, and taking
from https://www.ncbi.nl
precautions over
m.nih.gov/books/N BK148967/
everything. At second
trimester, continuous
vitamin intake and
undergoing for more
checkups. And for the
third trimester, she
started preparing
things for the baby
especially the hospital
papers and the baby’s
name. Overall, the
patient has a positive
output over having
their first baby.
child, her method of
feeding her baby was
breastfeeding and
eventually moved to
bottle feeding using
formula after 2
months.
GPTPALM SCORING

GRAVIDA – 2 PARITY – 1

T P A L M
1 1 0 1 0

PARITY BIRTHDATE GENDER TYPE OF HOSPITAL CONDITION COMPLICATIONS FEEDING HISTORY

/ YEAR DELIVERY AT BIRTH OF LABOR TYPES OF FEEDING

January, Male Cesarean Manila Nagkaron Nagkaron ng 2 months

1 2011 delivery ng complication due breastfeeding and
complicatio to failed induction the rest is formula
n due to of labor. Also, the (bottle feeding).
failed chord coil of the
induction of baby
labor. Also,
the chord
coil of the
baby.

9. Social profile  Patient J. T. doesn’t • Drinking alcohol, smoking or taking drugs

a) Cigarettes and a) “Hindi ako umiinom at drink alcohol and during pregnancy or while breastfeeding
alcohol use (still hindi rin ako doesn’t smoke, no can affect your child's health. Women
using now or not? naninigarilyo”. substance uses and who are pregnant, trying to conceive or
What are the b) “Multivitamins lang abuse, and no history breastfeeding should avoid smoking,
amounts and iniinom ko” of spouse abuse. drinking alcohol or taking illegal drugs.
frequencies?) c) “Wala naman”  Before pregnancy, the Reference: nidirectgovuk. (2020).
b) Are you taking any d) “Wala naman” patient Is taking Alcohol, smoking and drugs in pregnancy.
medications before Retrieved from https://www.nidirec
 pregnancy (amount multivitamins. t.gov.uk/articles/alcohol-smoking-and-
and frequency)? drugs-pregnancy
c) Substance use and • Abuse, whether emotional or physical, is
abuse (amount and never okay. Unfortunately, some women
frequency) experience abuse from a partner. Abuse
d) Spouse abuse crosses all racial, ethnic and economic
lines. Abuse often gets worse during
pregnancy. The American College of
Obstetricians and Gynecologists (also
called ACOG) says that 1 in 6 abused
women is first abused during pregnancy.
More than 320,000 women are abused
by their partners during pregnancy each
year.
Reference: March of Dimes. (2020). ABUSE
DURING PREGNANCY. Retrieved from
https://www.march ofdimes.org/pregna
ncy/abuse-during- pregnancy.aspx
9. HYGIENE OF PREGNANCY
(A typical day information about a woman’s current nutrition, elimination, sleep, recreation)

Before pregnancy During pregnancy

Nutrition Unhealthy things such as Changed diet to more vegetables

drinking coffee and eating junk and fruits. As well as removing
food often. coffee.

Elimination Daily elimination every Every 2 days due to constipation.

morning.

Sleep and rest Sleep very late due to Easier to fall asleep. At least 2 naps
insomnia. a day and getting 5-hour sleep at
night.

Recreation Doing DIY furniture and heavy Can’t do heavy work.

lifting

Hygiene Take a bath every day. Mas Still the same.

madalas pag wa-wash within
the day

Note: The content of this antenatal assessment and history taking came from both recorded and unrecorded
conversation between us and the patient since we escorted our interviewee on her way home.
 Review of System
A. General status (overall impression of your client) - Weight loss since pregnancy; Well-nourished; Healthy
diet; Meal Pattern: 3/day
B. Head - Normal
C. Eyes – Normal
D. Ears - Normal
E. Nose - Normal
F. Mouth - Normal
G. Neck - Normal
H. Breasts – Sore breasts (according to the patient)
I. Respiratory system - Normal
J. Cardiovascular system - Normal
K. Gastrointestinal system - Normal
L. Genitourinary system - Normal
M. Extremities – Normal

PHYSICAL ASSESSMENT
A. Date and time: 03:37 pm, October 5, 2022
B. Vital signs:
· Temp – 36.7
· BP – 95/60
· PR - 99
· RR - 20
C. Regional Examination (Indicate findings using descriptive forms, inspection, palpation, percussion,
auscultation
Region / body system Method of Normal findings Actual findings Deviation from
inspection normal
1. Skin INSPECTION - Varies from light - No abnormal - Pallor, cyanosis,
to deep brown; pigmentation, jaundice,
from ruddy pink bleeding, rash, or erythema
to light pink; from other lesions. - Areas of either
yellow overtones hyperpigmentatio
to olive. n or
- Generally hypopigmentatio
uniform except in n.
areas exposed to
the sun; areas of
lighter
pigmentation
(palms, lips, nail
beds) in dark-
skinned people.
PALPATION - When pinched, - Skin warm, dry, - Skin stays
skin springs back with good turgor. pinched or
to previous state - No presence of tented.
(elastic); may be edema -Generalized
slower in adults. hyperthermia/hy
- Temperature is pothermia,
uniform; within localized
normal range hyperthermia/hy
- No edema pothermia.
2. Nails INSPECTION - Convex - Nails are - Spoon nail,
curvature; angle translucent, clubbing
of nail plate shiny, and firm. - Excessive
about 160-degree thickness or
angle thinness or
 - Smooth texture presence of
- Intact epidermis grooves or
furrows
- Hangnails;
paronychia
PALPATION - After performing - Capillary refill - Bluish or
blanch test of time: Normal purplish tint;
capillary refill, pallor
there must be a
prompt return of
pink or usual
color
3. Scalp and Hair INSPECTION - Evenly - Hair is in normal - Patches of hair
distributed hair texture and (e.g., alopecia)
-Thick hair distribution. - Very thin hair
- Resilient hair - flaking, sores,
lice, nits, and
ringworm
PALPATION - No infection or - Healthy hair and - Hirsutism in
infestation smooth. women or
- No masses, naturally absent
nodules, or any or sparse leg hair
prominence. in men
4. Skull and face INSPECTION - Rounded; - Normocephalic - Lack of
smooth skull without scalp symmetry;
contour lesions. increased skull
- Symmetric or - Sensation intact size with more
slightly over face. No prominent nose
asymmetrical facial asymmetry, and forehead
facial features muscles of facial - Increased facial
- Symmetric facial expression intact. hair; low hair line
movements - Asymmetrical
facial movements
5. Eyes INSPECTION - Eyelashes, - Hair is evenly - Loss of hair;
 eyebrows, and distributed, skin scaling and
eyelids’ hair is intact. flakiness of the
evenly - Eyebrows are skin.
distributed. symmetrically - Unequal and
- Cornea is aligned. movement of
transparent and - Cornea is eyebrows.
smooth. transparent and alignment
smooth; the - Redness,
details of the iris swelling, flaking,
are visible. rusting, plaques,
- Pupils equal discharge,
round, react to nodules, and
light and lesions.
accommodation
PALPATION - Bulbar - Transparent; - Jaundiced
conjunctiva is capillaries sclera, excessively
transparent; sometimes pale sclera,
capillaries evident; sclera lesions or nodules
sometimes appears white - Opaque, surface
evident. - Conjunctivae not smooth
- Palpebral pink, sclerae
conjunctivae is white, without
pink without jaundice. NO
jaundice. lesions.
6. Ears INSPECTION - Auricle’s color is - Auricle’s color is - Bluish color of
same as the skin; same as the skin; earlobes;
Symmetrical Symmetrical excessive
- Sound is heard - Hearing intact redness;
in both ears; Air- bilaterally by Asymmetry
conducted Rhine’s Test. - Bone
hearing is greater conduction is
than bone- equal to or longer
conducted than air
hearing. I.e., conduction time
 AC>BC (Positive (Negative Rhine)
Rhine)
PALPATION - Auricle is - Ears without - Lesions; flaky
mobile, firm, and deformity, and scaly skin.
not tender. external - Tenderness
tenderness or when moved or
discharge pressed
7. Nose INSPECTION - External nose is - Nose is - Asymmetric
symmetric and symmetric; has - discharged from
straight; no no masses or any nares
discharge or bulges. - Localized area of
flaring uniform redness or
color. presence of skin
lesions.
PALPATION - Not tender, no - Nose without - Tenderness on
lesions. deformity, palpation; Masses
external and bulge.
tenderness or
discharge, and
lesions.
8. Mouth and INSPECTION - Outer lips are - Lips normal - Pallor; cyanosis
pharynx uniform pink color, without - Blisters,
color; soft, moist, lesions. Able to generalized or
smooth texture purse lips. local swelling;
- Symmetry of - Teeth present, fissures, crust, or
contour good dental scales
- Ability to purse hygiene - Inability to purse
lips - Tonsils not lips
- 32 adult teeth; enlarged - Missing teeth;
Smooth, white, - Palate elevates ill-fitting
shiny tooth symmetrically, dentures; brown
enamel gag intact. or black
discoloration of
the enamel
 PALPATION - No retraction of - Gums and - Receding,
gums mucous atrophied gums;
membranes pink swelling that
without bleeding partially covers
the teeth
9. Neck INSPECTION - Muscles equal in - No visible mass - Unilateral neck
size, head or bulges; swelling; head
centered symmetrical tilted to one side
- Coordinated, - Smooth - Muscle tremor,
smooth movements with spasms, or
movements with no discomforts stiffness
no discomforts - Limited range of
motion; painful
and involuntary
movements;
PALPATION - Lymph nodes - No masses or - Enlarged,
not palpable tenderness palpable, possible
- Thyroid gland is - Trachea midline. tender
not visible - Thyroid not - visible
- Gland ascends palpable diffuseness or
during swallowing - Lymph Nodes: local enlargement
but is not visible Occipital, pre- - Gland is not fully
and postauricular, movable with
submandibular, swallowing
anterior or
posterior cervical,
or supraclavicular
nodes not
enlarged.

DOCUMENTATION