PHYSICAL EXAMINATION
Name: _Patient X___________________________
Chief Complaint: Abdominal pain, cramps____
Vital Signs: T: 36.1˚C RR: 25cpm PR: 113bpm SpO2: 94% BP: 100/60 mmHg Pain Score: 10/10
GENERAL
Date: _March 13, 2023___
Height: 1.49 m Weight: 87 kg
BMI: 39.87
Received patient lying on bed, awake, conscious, coherent, oriented to time, place, and person. With ongoing IVF of PNSS 1L regulated at 20cc/min
hooked at left arm metacarpal vein, intact and infusing well. Presence of peripheral edema on upper (forearms) and lower (from foot to shin and
calves) extremities noted. Appeared lively and conversant. Has poor personal hygiene.
Head: Head is normocephalic and atraumatic without visible or palpable masses, depressions, or scarring; non-tender. Hair is black in color with
small variations of gray, of normal texture, and evenly distributed.
Eyes: Conjunctivae are pink, sclera are white and anicteric, without exudates or hemorrhage. No en- or exophthalmos or ptosis of lids. EOM
intact, PERRLA. Visual fields intact to confrontation.
HEENT
Ears: Yellow cerumen noted on bilateral ear canals. External ears free of lesions, masses, or tenderness. Pinna and ear canal are non-tender and
without swelling. Hearing is intact with good acuity to whispered voice.
Nose: Runny nose noted. Nose is normally shaped and without deformity. No palpable mass or lesions on external nose.
Throat and Mouth: Dental caries and cavities noted. Lips are pink. Oral mucosa is pink and moist. Tongue normal in appearance without lesions
and with good symmetrical movement. No buccal nodules or lesions noted. Pharynx is normal in appearance without tonsillar swelling or
exudates. No adenopathy noted.
INTEGUMENTARY
Stretch marks (striae distensae) noted on abdomen. Pitting edema present on upper (forearm) and lower (from foot to shin and calves) extremities
with edema grade of 1+. Skin is generally dry with good turgor. Uniform body skin coloring of brown. Hair normal in texture and distribution. Nails
are normal (160 degrees), with pinkish colored nail beds on both right and left hands and feet. Body hair normal in texture and distribution. No
bleeding, rash, or other lesions.
CARDIOVASCULAR
Tachycardic with 113bpm HR. Hypotensive with BP of 100/60 mmHg. External chest is normal without lifts, heaves, or thrills. PMI is auscultated
in the 5th intercostal space at the midclavicular line. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity.
Capillary refills within 2 seconds.
RESPIRATORY
Chest wall is symmetric with equal chest. No signs of trauma. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezes.
Resonance is normal upon percussion of all lung fields. RR: 25cpm. SpO2: 94%.
GASTROINTESTINAL
EXCRETORY
Ovoid shaped abdomen with baby bump. Fundal height 36cm. Abdominal stretch marks (striae distensae) noted. Bowel sounds cannot be auscultated.
Liver, spleen, and kidneys are nonpalpable.
No presence of sweat noted. Patient is with indwelling foley catheter with 780mL dark-yellowish urine output.
MUSCULOSKELETAL
Pitting edema present on upper (hands) and lower extremities (from foot to shin and calves) with edema grade of 1+. Radial, popliteal, posterior
tibial, and dorsalis pedis pulses are nonpalpable. Full ROM of all joints in upper extremities with muscle strength grade of 4/5 bilaterally. Limited
range of motion of all joints in lower extremities with muscle strength grade of 1/5.
NERVOUS
Alert, oriented to time, place, person, and situation. Recent and remote memory intact. GCS: 15/15 (E4V5M6). Good insight and cognitive function.
12 cranial nerves intact. No aphasia, dysarthria or hoarseness. Gait and station normal.
REPRODUCTIVE
G2 P1. 36 weeks pregnant with 36cm fundal height. FHT:139 bpm.
REVIEW OF SYSTEMS
GENERAL
Generalized weakness noted. Weight unexpectedly increased during hospitalization.
Head: No headaches and dizziness reported.
Eyes: No eye problems reported.
HEENT
Ears: No ringing in ears or any hearing difficulties noted.
Nose: Runny nose noted. No paranasal sinus problems reported.
Throat and Mouth: Verbalization of occasional toothache with pain score of 7/10 noted.
INTEGUMENTARY
Slight increase of breast size reported. No problems of itching, rash, or hair loss reported.
CARDIOVASCULAR
Swelling of forearms and lower extremities present. History of anemia reported. No reports of irregular heartbeat, racing heart, or chest pains.
RESPIRATORY
EXCRETORY
MUSCULOSKELETAL
NERVOUS
REPRODUCTIVE
Cough experienced occasionally. No problems of shortness of breath, wheezing noted.
Urinates frequently before hospitalization. Urine is concentrated with red-yellow color and aromatic in odor.
Pain in legs while walking with pain score of 4/10 prior to admission reported. Pain increased with pain score of 10/10 upon admission.
Difficulty walking and maintaining balance noted. No frequent headaches, double vision, change in sensation reported
Last menstrual period was in July 19, 2021. With irregular menstrual cycle before the birth of first lived child.