PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: ______________

Vital Signs:
Temp: _________ RR: 15 cpm Weight: ______________
PR: 90 bpm BP: 130/80 mmHg Height: ______________

Observation: Received pt lying on bed is a 32-year-old female G1P2 @ 39 weeks of gestation c IV LR hooked at left arm infusing @ 125 mL/hr. pt was submitted for bed rest and bathroom privileges.

1. General (weight loss or Received pt lying on bed is a 32-year-old filipino female G2P1 @ 39 5/7 weeks of gestation, admitted at the labor and delivery in active labor @ 06hoo hours today. pt is
gain; fever, chills, night awake, alert, conscious and oriented to person, place, time and event. hooked c IV LR in left arm @ 125mL/hr. answered questions instantaneously; oriented to person, time
sweats; mood; stage of and place; mood and affect appropriate to situation, appropriate judgement and insight, memory intact. Body parts are bilaterally equal; PERRLA; mucous membranes are
development, race, sex; signs moist ; heart sounds are normal with no murmur; vital signs as follows:
of distress; position; O2 sat: 97% @ room air
cooperative or not; state if RR: 15 cpm
irritable, agitated or pleasant; PR: 90 bpm
etc.) BP: 130/80 mmHg
2. Head (headache, injury, H -(-) headache; normocephalic and atraumatic, positioned at midline, (-) tenderness, (-) Injury;
tenderness, etc.); Eyes E - conjunctiva normal, eyelids normal, EOMI, anicteric, Pt reported for visual changes; EOM (extraocular movement) are normal, pupils are equal, round, and reactive to
(change in visual fields, light, (-) scleral icterus, (-) bilateral periorbital edema present, no complaints of blurring or loss of vision;
glasses, blurring, diplopia, E - external ears, hearing grossly normal; symmetrical, (-) lesions in the area and no hearing problem, (-) no redness swelling or thickening;
pain, loss of vision, tearing, N - MMM (moist mucous membranes); symmetric in the midline, (-) obstruction, inflammation, and discharges;
dry eyes, etc.); Ears (change T - MMM (moist mucous membranes); patent and moist, (-) irritation in the area and swelling, (-) thyroid gland or lymph node enlargement.
in hearing, tinnitus, discharge,
dizziness, etc.); Nose
(allergies, sinus problem,
obstruction, polyps, sneezing,
epistaxis, etc.);Throat
(toothaches, loose teeth,
bleeding gums, mouth sores,
hoarseness, difficulty
swallowing, etc.)

3. Integumentary System no rash, no petechiae, no ecchymosis; without cyanosis, clubbing or edema; fair skin pigmentation and even hair distribution throughout the body (-) lesions, edema,
inflammation; strong pulses in all four extremities are noted and palpated. hooked c IV LR in left arm @ 125mL/hr

4. Respiratory System (-) chest pain, pressure, tightness, palpitations, respiratory rate @ 15 cpm; (-) respiratory distress, (-) tachypnea, (-) wheezing, (-) sputum, (-) hemoptysis; oxygen sat 97@
(chest pain, dyspnea, cough, room air.
amount and color of sputum,
hemoptysis, etc.)

Patient’s Name / Room No. | 1

5.Cardiovascular System (-) chest pain, pressure, tightness, palpitations; heart sound was normally heard c normal rate @ 90bpm regular rhythm with no murmur, (-) edema, (-0 claudication, (-)
(chest pain/ pressure/ endurance, BP @ 130/80 mmHg, (-) orthopnea
tightness, palpitations,
orthopnea, paroxysmal
nocturnal dyspnea, shortness
of breath, edema, claudication,
endurance, etc.)
6. Digestive System Moist mucous membranes, abdomen is soft, (-) distension, (-) tenderness (-) abdominal pain; normal bowel sounds upon auscultation, no changes noted. No signs of GERD are
(dysphagia, heartburn, ulcer, noted; (-) indigestion, ulcer, diarrhea, constipation; (-) blood in stool, black tarry stools, reduced calibre in stools; (-) haemorrhoids
GERD, indigestion, food
intolerance, diarrhea,
constipation, abdominal pain,
blood in stool, black tarry
stools, changes in bowel
habits, reduced caliber of
stools, hemorrhoids, etc.)
7. Excretory System (-) urgency, frequency; (-) nocturia, dysuria; (-) hematuria, pain upon urination; no signs and symptoms of recurrent infection, UTI.
(urgency, frequency, nocturia,
dysuria, hematuria, recurrent
UTIs, STD, incontinence, etc.)
8.Musculoskeletal System normal muscle strength, pt has no significant abnormalities or deformities; (-) Limitation of movement; (-) stiffness and joint pain; (-) swelling or redness; (-) arthritis; (-)
(limitation in movement, muscle spasm and muscle weakness. submitted for bed rest and toilet privileges
stiffness, joint pain, swelling
or redness, arthritis, muscle
spasms, muscle weakness,
etc.)
9. Nervous System oriented to person, time and place; mood and affect appropriate to situation, appropriate judgement and insight, memory intact

10. Endocrine System (-) heat/cold intolerance; hair is evenly distributed; skin is light warm to touch; lymph nodes not palpable; (-) thyroid gland enlargement; (-) polydipsia, polyuria, and
(heat/cold intolerance, weight polyphagia.
change, fatigue, polydipsia,
polyuria, polyphagia, changes
in hair distribution, etc.)
11. Reproductive System 32 years old female G2P1 @ 39 5/7 weeks of gestation

Patient’s Name / Room No. | 2