PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS
Date: October 4, 2021
Vital Signs:
Temp: 38.8C RR: 24rpm Weight 68kg
PR: 100bpm BP: 130/70mmHG Height: 165cm
Impression/Diagnosis: active labor, rupture of membrane
1. General (weight loss or Height appears to be within the normal range of stated age, The patient appears clean and groomed appropriately for her age, The patient is cooperative and
gain; fever, chills, night interacts pleasantly.
sweats; mood; stage of
development, race, sex;
signs of distress; position;
cooperative or not; state if
irritable, agitated or
pleasant; etc.)
2. Head (headache, injury, H-Head is symmetric, round, erect and in midline and appropriately related to the body size. Facial features are in proportion with each other. There is no
tenderness, etc.); Eyes presence of tenderness with the patient’s head.
(change in visual fields, E- Eyeballs are aligned symmetrically. Eyebrows are present bilaterally, move symmetrically as the facial expression changes and have no scaling or lesions.
glasses, blurring, diplopia, Pupils constrict when exposed to light using penlight. Extraocular movements intact. Anicteric sclera.
pain, loss of vision, tearing, E-Ears are aligned symmetrically with each other. There is no presence of any discharges.hearing grossly normal, mmm
dry eyes, etc.); Ears N-Nose is symmetric, in the midline and in proportion to other facial features. There are no presence of any skin lesions or inflammation.
(change in hearing, tinnitus, T- Tongue is normal in size. No reports of difficulty swallowing.
discharge, dizziness, etc.);
Nose (allergies, sinus
problem, obstruction,
polyps, sneezing, epistaxis,
etc.);Throat (toothaches,
loose teeth, bleeding gums,
mouth sores, hoarseness,
difficulty swallowing, etc.)
Skin color distribution is generally uniform except in areas exposed to sun, areas of lighter pigmentation such as palms, lips and nail bed. There are no
3. Integumentary System presences of thick sections or lesions on epidermis. no rash, no petechiae and no ecchymosis.
Patient’s Name / Room No. | 1
normal chest expansion, normal breath sounds. Respirations are even, unlabored and regular. No use of accessory muscles and no nasal flaring.
4. Respiratory System
(chest pain, dyspnea,
cough, amount and color of
sputum, hemoptysis, etc.)
5.Cardiovascular System (+) abdominal – thoracic type respiration bilateral symmetrical chest movement
(chest pain/ pressure/ Heart sounds S1, S2 auscultated, no no appreciable murmur, rub, or gallop
tightness, palpitations, pulse regular, normal volume, no radio-radial/radio-femoral delay, all peripheral pulses palpable, arterial wall normal.
orthopnea, paroxysmal There are no presence of edema.
nocturnal dyspnea,
shorntness of breath,
edema, claudication,
endurance, etc.)
6. Digestive System The patient has normal bowel movement. Abdomen is rounded and symmetric, without masses, lesions, pulsations or peristaltic waves. Umbilicus in midline,
(dysphagia, heartburn, without herniation, swelling and discoloration.
ulcer, GERD, indigestion,
food intolerance, diarrhea,
constipation, abdominal
pain, blood in stool, black
tarry stools, changes in
bowel habits, reduced
caliber of stools,
hemorrhoids, etc.)
The patient’s urine is clear and pale yellow in color.
7. Excretory System
(urgency, frequency,
nocturia, dysuria,
hematuria, recurrent UTIs,
STD, incontinence, etc.)
8.Musculoskeletal System There are no reports of joint pain, presence of swelling or redness, and limitation in the patient’s movement. normal muscle strength. The patient has no
(limitation in movement, significant abnormalities or deformities.
stiffness, joint pain, swelling
or redness, arthritis, muscle
spasms, muscle weakness,
etc.)
Patient’s Name / Room No. | 2
9. Nervous System The patient is able to maintain balance upon sitting or standing up. Cranial nerve I to cranial nerve XII is present with normal reflex. Patient’s reflexes are 2+,
which indicates normal responses upon assessment. oriented to person, time and place, mood and affect appropriate to situation, appropriate judgement and
insight, memory intact.
10. Endocrine System There are no signs of intolerance to heat or cold. The distribution of hair throughout the patient’s body is normal.
(heat/cold intolerance,
weight change, fatigue,
polydepsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
11. Reproductive System Female reproductive organ is fully developed with normal distribution of pubic hair.
Patient’s Name / Room No. | 3
