A.
GENERAL ASSESSMENT
The client is conscious, well-oriented of her present condition and showed interest with the
interview by responding quickly to questions. She has weight of 220 lbs. and height of 168
cm. Vital signs are; temperature of 36.8 degrees Celsius, pulse rate of 88 beats per minute,
respiration rate of 20 breaths per minute, and blood pressure of 130/80 mmHg. The client has
no obvious physical deformities or abnormalities. She looks tired and ambivalent with signs
of distress. The client is in an erect posture and coordinated by body movements, cannot
freely move, flex and extend her extremities, but can voluntarily move. Her mood is
appropriate to the situation, has appropriate response, comfortable and calm.
B. HEAD
Head is symmetric, round, erect, and in midline and appropriate to the body size. No tenderness
noted.
Skin is oily and chloasma noted.
Several pustules and macules present.
Temporal artery is elastic and not tender.
Present crepitation with movement palpated. No tenderness and swelling.
Mouth opens and closes fully. Lower jaw moves laterally 1-2cm in each direction.
B.1. EYES AND VISION
Eyelashes are evenly distributed and curved outward along with the margins.
The upper and lower lids close easily and meet completely when closed.
Bulbar conjunctiva is clear, moist, and smooth. Underlying structures are clearly visible.
Sclera is white and free of swelling and lesion.
The pupil, round with a regular border, is centered in the iris. Pupils are normally equal with 4
mm in size bilaterally.
Extraocular movements smooth and symmetric, with no nystagmus.
The reflection of light on the corneas are in the exact same spot on each eye which indicates
parallel alignment.
Corneal light reflex is symmetric.
The uncovered eye remains fixed straight ahead. The covered eye remains fixed straight ahead
after uncovered.
Pupillary response is constriction of the pupils and convergence of the eyes when focusing on the
whiteboard.
Both eye: no internal eye structure visualized.
Blurred vision reported.
B.2. EARS AND HEARING
Ears are equal in size with 5 cm bilaterally.
The auricle, tragus, and lobule are present symmetric bilaterally. The auricle aligns with the
lateral canthus of each eye and has a 10-degree angle of vertical position bilaterally.
Earlobes are free. The skin on the ears is smooth, without lesions, lumps, or nodules; color
consistent with that of the face. No discharge inspected.
Tympanic membrane is pearly gray, shiny, and translucent with no bulging and retraction;
landmarks are visible.
Auricle, tragus, and mastoid process nontender to palpation bilaterally.
Decrease in hearing and a sense of fullness in the ears are reported.
B.3. NOSE AND SINUS
Color is the same as the rest of the face.
The nasal structure is smooth and symmetric with no tenderness.
Frontal and maxillary sinuses are nontender; crepitus is palpable.
The nasal septum is intact and free of ulcers or perforations.
Sinuses are not tender on percussion.
Nasal “stuffiness” and epistaxis are noted.
B.4. MOUTH
Lips are smooth and moist without lesions and swelling.
Light yellow and smooth teeth, with no malocclusion or obvious caries.
Presence of hypertrophy of the gingival tissue.
Gum is pink, moist, and firm, with tight margins to the teeth. No gum ulceration or lesions
palpated.
Tongue is pink, moist, a moderate size with papillae present. No lesions are present.
Tongue’s ventral surface is smooth, shiny, and pink with visible veins and no lesions.
Hard palate is pale, with firm, transverse rugae.
Uvula is a fleshy, solid structure and hangs freely in the midline; symmetric elevation of the soft
palate.
Jaws aligned with no deviation seen with biting down.
No tongue ulceration or lesions palpated.
C. NECK
Neck is symmetric, with head centered and without bulging masses.
Landmarks are positioned midline.
Trachea is midline.
Lobes feel smooth, rubbery, and free of nodules.
Small cervical nodes palpable.
Thyroid gland not palpable but thyroid is slight enlarged.
No deviation or masses noted.
D. CHEST
D.1. POSTERIOR
There is evidenced of outward expansion of the abdomen and lower ribs and return to
resting position on expiration.
Scapulae are symmetric and non-protruding.
Shoulders and scapulae are at equal horizontal positions.
The spinous processes appear straight.
The thorax is symmetric with ribs sloping downward at approximately a 45-degree angle
in relation to the spine.
Skin and subcutaneous tissue are free of lesions and masses.
Client’s fremitus is symmetric and easily identified in the upper regions of the lungs.
Upon palpation of posterior thorax, client reports no tenderness, pain or unusual
sensations.
D.2. ANTERIOR
Inspection reveals that there is increased anteroposterior diameter, thoracic breathing
with slight hyperventilation.
Sternum positioned at midline and straight with no retractions observed.
Breath sounds and voice sounds same anteriorly as described posteriorly.
Venous congestion is noted with prominence of veins.
Color of breast is light brown with smooth texture, and no edema.
Breast skin is light brown with darken areola and nipple. It is enlarged with striae
gravidarum evident. It is smooth bilaterally.
Montgomery tubercles are prominent.
Nipples are everted bilaterally, with no dryness or lesions.
Breast size is increased and nodular and sensitive with no sign of dimpling, retraction
lesions, or erythema.
Temperature of breast tissue is same as chest wall.
Hyperpigmentation of nipples and areolae is evident.
Soft systolic murmurs are audible.
E. ABDOMEN
Abdominal skin is light brown with striae, without lesions or rashes. Linea nigra is present.
Umbilicus is midline and recessed, darkening with no bulges.
Abdomen is enlarged with striae gravidarum. Presence of pinkish-red streaks with slight
depressions in the skin is noted.
Upon auscultation for bowel sounds, series of intermittent, soft clicks, and gurgles are heard at a
rate of 15 per minute.
Liver, spleen, kidneys, and urinary bladder not palpable.
Uterus is palpable. The uterine contracts and feels firm.
No evidence of fluid wave or shifting dullness.
Uterine size is 20 cm at 20 weeks’ gestation.
LEOPOLD’S MANEUVER
Presentation is cephalic and ROA.
Left side of the abdomen with round nodules palpated while the right side is smooth.
The unengaged head is round, firm, and ballotable.
The fetal head has not descended into the maternal pelvic inlet.
Fetal heart rate of 130 beats/min.
F. EXTREMITIES
F.1. UPPER EXTREMITIES
Skin is with light complexion with smooth texture, no mass and lesions.
Shoulders and arms with no tenderness with edema on both sides.
Temperature of shoulder and arms are same as the chest.
Elbows are symmetric, without deformities, redness, with swelling.
The client’s axillary skin is darkening, free of redness, rashes, or irritation bilaterally.
Axillary hair has been removed bilaterally with darkening axillae.
No distinct mass is noted.
No infection or rash noted. There are no palpable axillary nodes bilaterally.
Epitrochlear lymph nodes are nontender without nodules.
Wrist are nontender and free of nodules.
F.2. LOWER EXTREMITIES
Skin coloration is light complexion with a smooth texture with no lesions and masses. Presence
of pinkish-red streaks are noted.
Hairs are distributed evenly.
Knees are symmetric, hollows present on both sides of the patella, no swelling or deformities.
Lower legs are aligned with the upper legs. No tenderness and no nodules. Muscles are firm
Toes point forward and lie flat. Toes and feet are aligned with lower leg. Skin is smooth and free
of corns and calluses, with longitudinal arch.
No pain, heat, swelling, or nodules are noted in the ankle and feet
G. FEMALE GUT
Visual inspection discloses normal hair distribution of the mons pubis free of lesions with no
signs of infestation.
Enlarged labia and clitoris and parous relaxation of introitus.
No discomfort or discharge with examination.
No cystocele or rectocele.
