PATIENTS DATA

Name of Patient: Castor, Evangeline S.

Age: 44 years old

Sex: Female

Status: Married

Address: Datu Panas, Buug, Zamboanga Sibugay Province

Date of Birth: 16 Decaember 1973

Place of Birth: Compostela, Buug, Zamboanga del Sur

Religion: Roman Catholic

Occupation: Teacher

Spouse: Castor, Rey A.

Obgyne History:

Menarche: 14 years old

LMP: May 20, 2016

OB Index: G2 P1

EDC: February 27, 2017

AOG: 37 weeks and 1 day

PHYSICAL EXAMINATION

BP 240/140mmhg CR 68bpm RR 32cpm t - 35.0oC

WT 43. 5 kgs.

INTEGUMENT

SKIN: Pale and diaphoretic, cold clammy skin.

HAIR: the hair of the clients is thick, silky hair is evenly distributed
and has a variable amount of body hair. There are no signs of infection
observed.
NAILS: pale nail beds.

HEAD

HEAD: the head of the client is rounded, normocephalic and

symmetrical.
SKULL: there are no nodules or masses and depressions when
palpated.
FACE: the face appeared smooth and has uniform consistency and no
presence of nodules and masses.

EYES AND VISION

 EYEBROWS: hair is evenly distributed. The clients eyebrows are
symmetrically aligned and showed equal eye movement when asked to
raise and lower eyebrows.
EYELASHES: eyelashes appeared to be equally distributed and curled
slightly outward.
EYELIDS: there were no presence of discharges, no discoloration and
lids close symmetrically with involuntary blinks approximately 15 20
times per minute.
EYES: the bulbar conjunctiva appeared transparent with few capillaries
evident. The sclera appeared white. The palpebral conjunctiva
appeared shiny, smooth and pink. There is no edema or tearing of the
lacrimal gland. Cornea is transparent, smooth and shiny and the details
of the iris are visible. Pupils equally round respond to light
accommodation.

EARS AND HEARING

EARS: the auricles are symmetrical and have the same color with her
facial skin. The auricles are aligned with the outer cathus of eye. The
pinna recoils when folded.

NOSE AND SINUS

NOSE: the nose appeared symmetric, straight and uniform in color.

There was no presence of discharge or flaring. When lightly palpated,
there were no tenderness and lesions.
MOUTH: the lips of the client are pale, moist, and symmetric and have
a smooth texture.
TEETH AND GUMS: there is no discoloration of the enamels, no
retraction of gums, pinkish in color gums. The buccal mucosa of the
client appeared as uniformly pink, moist, soft, glistening and with
elastic texture. The tongue is centrally positioned. The uvula is
positioned in the midline of the soft palate.

NECK

The neck muscle is equal in size. The client showed coordinated,

smooth head movement with no discomfort.
The lymph nodes are not palpable.
The trachea is placed in the midline of the neck.
The thyroid gland is not visible on inspection and the glands ascend
during swallowing but are not visible.

THORAX, LUNGS AND ABDOMEN

LUNGS/CHEST: Harsh breath sounds, intercostal chest equal,

tacchypneic.
HEART: there were no visible pulsations on the aortic and pulmonic
areas. There is no presence of heaves or lifts.
ABDOMEN: Globular, 28 cm fundic height, (+) bloody show, cervic 3
4 cm dilated, fetal heart tone 156 bpm at right para umbilical
area, (+) bilateral kidney punch.

EXTREMITIES

MUSCLES: the muscles are not palpable with the absence of tremors.
They are normally firm and showed smooth, coordinated movements.
BONES: there were no presence of bone deformities, tenderness and
swelling.
 JOINTS: (+) grade 1 ankle edema.