A.

PHYSICAL ASSESSMENT Date performed:

July 22, 2013

1. Head-to-Toe Examination 1.1 General Survey The patient was assessed lying on bed in a left side lying position, awake, irritable and complaining of severe abdominal pain in her right lower quadrant. There is noted facial grimace and guarding behavior with the pain scale of 10/10. The patient was 3 months pregnant with the LMP; April 28, 2013. The fetal heart tone is 140bpm. The patient has IVF D5ER 1L + 4amp duvadilan x 20gtts infusing in her left metacarpal vein. She is on None per Orem diet. She was properly groomed and without body odor. The patient age is appropriate to her body. She was slightly cooperative and responsive during the entire assessment. 1.2 Vital Signs BP: 120/70 R: 21 breathes/min PR: 74 bpm T: 36

1.3 Head and Face a. Cranium The patients head is normocephalic and proportional to body size. Presences of nodules or masses are not noted. The cranium has a wellrounded skull shape and with smooth, uniform consistency. Theres no a lesion or masses noted. b. Temporal arteries The temporal arteries are palpable and pulsating well c. Face Facial features and movements are symmetrical. The patient is able to raise her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight tiredness and pain. Equal size of palpebral fissures, no signs of edema and lesions.

d.

Cranial nerves V and VII The cranial nerves V and VII: function is normal because patient was able to elicit the blink. Also, he was able to do facial movements equally such as frowning. Nose and cranial nerve I

e.

The external nose is symmetrical, straight and uniform in color. Nasal flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and right nares were patent, with no discharges; air could freely move in and out when the patient breathes. The nasal septum is intact and in the midline without deviations. The frontal and maxillary sinuses were non-tender upon palpation. Sense of smell was good. Patient was able to differentiate water from that of alcohol, through scent

1.4 Eyes and vision a. External eye structure The external eye structures are normal because eyebrows are evenly distributed, symmetrically aligned. The skin is intact.. There is no noted edema and tenderness in the lacrimal gland. The eyelashes are also equally distributed. Sclera is not anicteric and conjunctiva is pale. The pupils are black and equally rounded. b. Extraocular muscle function (cranial nerve III, IV & VI) The client can perform the six cardinal signs of gaze. There is coordination with his two eyes. c. Pupillary reflexes The pupil is 2-3 mm round. Pupils are equally round reactive to light and accommodation. The pupil constrict when exposed to light and does not eventually dilates when there is no light.

d. Internal eye structure with ophthalmoscope N/A

1.5 Ears & Hearing a. External ear The external ear is normal because the auricle has the same color as the facial skin. The auricle is aligned with the outer canthus of the eye about ten degrees from vertical. The pinna recoils when it is folded. It has a smooth contour and has no lesions. There is no deformity. b. Hearing The client has no difficulty in hearing, because she responded to all the questions that I asked. c. Ear canal and tympanic membrane with otoscope. N/A

1.6 Neck a. Musculoskeletal structures The muscles in her neck were equal in size. His neck movement was coordinated and difficulty in moving was not noted. He was able to flex, hyperextend, laterally flex and rotate her neck without distress. He can also turn his head on one side against the resistance of our hand with the similar strength and shrug his shoulders up against the resistance of our hand with equal strength. The trachea is in the midline.

b. Lymph nodes The lymph nodes are non-palpable. c. Thyroid gland The thyroid gland has no enlargement noted upon palpation.

d. Musculoskeletal function and cranial nerve XI The musculoskeletal function and cranial nerve XI function is normal because the patient was able to move his neck from left to right, up and down with resistance. He can also rotate his head and shrug his shoulders without any limitations. e. Carotid arteries The carotid arteries are pulsating with symmetric pulse volumes.

1.7 Upper Extremities a. Musculoskeletal structures, skin, nails Muscles are equal in size. There is no weakness noted. The capillary refill is 3 seconds on both right and left hand nail beds. The five fingers are intact. b. Musculoskeletal functions The patients radial and brachial pulses were regular. Good range of motion was noted. Palm is able to stay in both prone and supine in a good manner without difficulty. She was able to exhibit strong hand grip on both arms. Client was able to extend both arms. Reflex on the upper extremity was good. No hand tremors noted. c. Brachial and radial arteries The brachial and radial arteries are pulsating well with a grade of 3+, symmetric and thrusting quality in the right and left wrist

d. Deep tendon reflexes N/A

1.8 Anterior Chest a. Breasts and axillae The breasts have no tenderness, masses or nodules and the 2 nipples are brown in color. Skin is uniform is pale; it is also smooth and intact. The axilla has no presence of hair and lymph nodes have no masses, tenderness and nodules. b. Thorax The patient has a regular and normal breathing pattern; quiet and rhythmic respirations, with respiratory rate of 21 cyles in one full minute. No tenderness and masses upon palpation. No adventitious breath sounds on both left and right lung fields were heard during auscultation. Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed There is no difficulty of breathing; The chest expansion is symmetric with clear breath sounds. No lesions, masses noted. c. Precordium The apical pulse can be auscultated and no irregularities in the heart beat rhythm were noted. With no abnormal heart sounds or murmurs.

1.9 Back a. Musculoskeletal structure The musculoskeletal structure is normal because spine is midline and shoulder and hips are at same height. The skin is intact and without lesions. b. Fist percussion over spine and kidneys There is no noted tenderness over kidney. Percussion of the kidney resulted to dull sound and the spine has a blunted sound.

1.10

Neck veins The veins on the left side and right side of the neck are pulsating not distended.

1.11 Abdomen a. 4 abdominal quadrants Unblemished skin, uniform in color with symmetric contour. There is a symmetric movement caused by respiration. Tympanic sound upon percussion. The right lower abdominal quadrant has direct tenderness upon palpation. Negative rebound, obsturator, psoas and rousings signs.

b. Specific organs Liver There is no enlargement of the liver noted when client held her breath upon inspection. Borders are smooth upon palpation. There is dullness upon percussion and the site is not tender Spleen The spleen has no evidence of enlargement when client held her breath upon inspection and is not palpable Kidneys The kidneys have a dull sound during percussion and are palpable and no tenderness is noted. 1.12 Lower Extremities a. Musculoskeletal structures, skin, and toe nails Muscles are equal in size on both sides of the body. It has no contractures and tremors. Skin is intact, no lesions; capillary refill is 2-3 seconds b. Musculoskeletal function Equal muscle strength and muscle tone on each leg side. It exhibits coordinated and firm movements. c. Popliteal,posterior tibial and pedal arteries The popliteal pulse is pulsating well. d. Deep tendon reflexes and planter reflex N/A

1.13 Genito-Urinary( Internal Examination) Cervix is pink, smooth with positive curd- like discharge attached to the cervix and lateral vaginal walls. There is vaginal candidiasis noted. The cervix is soft, closed non tender. The uterus is 10-12 weeks in size, nontender with positive right adrenal tenderness. No masses on left adrenal cortex.

Summary of abnormal findings: The client is irritable and slightly participating in the procedure. Her right lower abdominal quadrant has direct tenderness upon palpation. Cervix has positive curd- like discharge attached to the cervix and lateral vaginal walls. There is vaginal candidiasis noted. There is positive right adrenal tenderness. Reference: Marieb, E. 2006. Essentials of Human Anatomy and Physiology 8th Edition; Kozier, B. 2004. Fundamentals of Nursing 7th Edition