I.

PHYSICAL EXAMINATION

Breasts=Refused to Undergo
Uterus= Contracted and firm; 1 fingerbreadth below umbilicus
Bladder=(-) distention
Bowel Sounds=11/minute, passed flatus twice, not yet defecated since delivery; Urinated before 6 AM,
saturated 1 maternity diaper, yellow urine, (-) foul smell
Lochia=pinkish, minimal discharge
Episiotomy=Refused to Undergo
Homan’s Sign=[ichek bukas]
Emotional Status=calm

GENERAL SURVEY: uniform convergence

conscious, coherent normal visual acuity
oriented to time, person and place intact visual field
(-) signs of distress
development: mesomorph, well-developed, looks EARS:
according to age external pinnae: normoset, symmetrical, (-)
well-nourished tenderness
calm emotional state (-) impacted cerumen & discharge
coordinated gait symmetrical gross hearing
(-) hearing deficit
VITAL SIGNS:
T: 36.5 C, axillary NOSE:
PR: 97/min, regular, strong nasolabial fold: symmetrical, (-) alar flaring
RR: 15/min, regular, unlabored septum: midline, (-) perforation
BP: 110/70 mm Hg, sitting mucosa: pinkish, (-) discharge
weight: (input) kg nostrils: (-) obstruction, masses & lesions
height: (input) cm symmetrical gross smell
(-) tender sinuses
SKIN:
(-) pallor, jaundice, flushed & cyanosis MOUTH:
smooth texture lips: (-) pallor, cyanosis, dryness/cracks & lesions
good skin turgor tongue: midline, (-) atrophy, fasciculation & lesions
cool temperature teeth: intact, (-) dental carries
neither too dry nor too moist gums & mucosa: pinkish, (-) lesions
(-) ecchymosis intact speech
(-) lesions: (-) edema
PHARYNX:
HEAD: uvula in midline
normocephalic, symmetrical pinkish mucosa
(-) masses (-) inflammed tonsils
hair: fine, normal distribution, (-) alopecia
scalp: (-) dandruff & lice, (-) lesions, masses and NECK:
tenderness trachea in midline
lymph nodes: non-tender, non-palpable
EYES: thyroids: non-tender, non-palpable, not enlarged
lids: symmetrical, (-) edema, lesions & ptosis normal ROM, (-) neck rigidity
periorbital region: (-) edema, sunken & discoloration
conjunctiva: pinkish, (-) lesions & discharge
anicteric sclera CHEST AND LUNGS:
cornea & lens: smooth, clear, (-) lesions eupnea, (-) use of accessory muscles
pupils: equal, 5 mm, briskly & uniformly reactive to APL ratio 1:2, (-) barrel, funnel & pigeon chest
light & accommodation symmetrical chest expansion
symmetrical and descending tactile fremitus
resonant to percussion
breath sounds: vesicular [peripheral areas],
bronchovesicular [interscapular area] &
bronchial [manubrium]

HEART:
pericardium: flat, normodynamic, (-) tenderness,
heaves & thrills
PMI: apical, 5th ICS LMCL
S1 & S2 regular, S1 louder at apex, S2 louder at base
heart sounds: distinct, regular, (-) extra sounds

BREAST AND AXILLAE:

Refused to undergo Breast Examination

ABDOMEN:
(-) dilated veins, scars, rashes (+)striae
Flabby, globular & symmetric
(-) visible pulsations & peristaltic movement
(-) bruits
bowel sounds: normoactive,11/min
percussion: tympanic [LUQ, RLQ, LLQ], dull [RUQ]
(-) muscle guarding, direct/rebound tenderness
(-) masses & enlarged organs

BACK AND EXTREMITIES:

peripheral pulses [brachial, radial]: symmetrical,
regular & strong
nails: pinkish, (-) clubbing & blanching
capillary refill time: 0-1 sec
joints: full ROM, (-) swelling, redness, tenderness,
warmth & crepitation
muscles: equal in size & normal tone, (-)
fasciculation, tics & tremors
spine in midline
(-) CVA tenderness