Our client C.R.T.

is a 24 years old female who lives in Barangay Agdao, Davao

City.
I- GENERAL SURVEY
As we observed her body built is endomorph which is a stocky person. With a height
of 155 cm and weighs 92 kilograms which results to a body mass index of ___ which is
_______. As we let our client stand against the wall her shoulders lied flat we observed
that she has a kyphotic posture which has an increased forward curvature because of
pregnancy. As we do our interview in our client it shows that she is cooperative, alert in
answering our questions, responsive and shows willingness. She is able to answer in an
organized manner with appropriate words. As we took her vital signs with our client
sitting, her temperature is 36.4 degrees Celsius, a pulse rate of 78 beats per minute, a
heart rate of 82, a respiratory rate of 22 and a blood pressure of 110/80 which are all
regular.
II- SKIN
As we inspect her skins general color is brown it shows uniformity without any
abnormalities, there were no presence of edema and other skin lesions . Skin integrity is
intact and no presence of redness. She has smooth texture and a good skin turgor. As
we have compared the feet and both hands using the back of our hands her skin
temperature is warm with dry moisture. There was also no presence of excessive
sweating. As we have observed at her posterior neck there is a presence of linea nigra
a dark vertical line that normally appears on pregnant women. As we have observed her
nails were clean and properly trimmed with a good capillary refill time. Her nails were
pink in color with some longitudinal ridging without any deformities.
III- HEAD
As we have observed her head is normocephalic which is rounded and smooth skull.
As we palpate her head, her anterior and posterior fontanelles were closed. Heads
shape is symmetrical without any enlargements. Her scalp is clean without any
presence of dandruff, lies and lesions. Her hair was normally distributed with a fine silky
hair. Without presence of any abnormalities like alopecia, hirsutism and infestations. As
we observed, her face has a symmetrical facial features palpebral fissures were equal
with a symmetric nasolabial folds. Also a strong muscle strength of jaw.
IV- EYES
As we inspect her eyes there were no presence of edema and hollowness. As we
checked for her eyebrows it is aligned and hair were normally distributed. As we let her
raise and lower her eyebrows it has a symmetrical movements, eyelids also were
symmetrical. As we observed her lashes were curled outward and evenly distributed. As
we palpate her lacrimal duct using the tip of our index finger, there are no presence of
edema and tenderness noted. Cornea was shiny and smooth without presence of
lesions. In assessing for our clients pupil we used a penlight, pupil equally round, react
to light and uniform accommodation. As we assessed for extraocular muscles we stand
in front of the client and hold a penlight and ask to follow penlight with eyes only from
superior oblique, superior rectus, lateral rectus, medial rectus, inferior rectus and inferior
oblique. For her eyes convergence, we ask our client to follow the object as it moves
toward the bridge of the nose. Which results the eyes to converge, eye movement were
coordinated.
V- EARS
As we palpate for her pinna it is firm, and recoils. There are no presence of lesions
and tenderness. External canal has no discharges. Using a penlight, as we inspect for
the tympanic membrane it is pearly gray and semi transparent. As we assess for the
gross hearing acuity we performed the whispered word test we let her occlude one ear
with finger then whispered non consecutive numbers and let the client repeat. Our client
was able to repeat words accordingly.
VI- NOSE
In assessing her nose, it is uniform in color, symmetrical, no discharges, no nasal
flaring. Nasal septum is straight and not perforated. There are no tenderness and
lesions noted. Air moves freely as client breathes through the nares. Nasal septum is in
midline and intact. As we palpate the frontal, ethmoid, sphenoid and maxillary sinuses
there are no tenderness noted.
VII- MOUTH
In inspecting our clients lips it is uniform pink in color, moist and smooth. Using a
penlight we inspect the entire oral cavity, it is pink without ulcers. Tongue is pink, moist,
slightly rough, moves freely and has a thin white coating. There are no swelling and
ulceration noted. There are some missing teeths and presence of tartar. Palates, gums
and mucosa are pinkish.
VIII- PHARYNX
As we inspect the pharynx using penlight, uvula is in midline, pinkish and smooth.
Mucosa is also pinkish with no presence of swelling and ulceration. Tonsils are not
inflamed. As we assessed for the gag reflex we used a sterile tongue depressor and
placed in on the posterior tongue in which the client has a positive result.
IX- NECK
As we inspect for the appearance and movement of the neck, flexion is 45 degrees,
lateral abduction is 40 degrees, extension 55 degrees and rotates at 70 degrees. As we
palpate the trachea, we place our thumbs along each side of the trachea near lower part
of the neck results to an equal distance on tracheas outer edge and the
sternocleidomastoid muscle in both sides. During auscultation of the trachea, presence
of bronchial and tubular breath sounds was noted. As we palpate the lymph nodes, it is
palpable. As we inspect the jugular vein for distention we asses our client in semi
fowlers position and uses a penlight. Jugular vein distention is absent.
X- THORAX
In assessing the thorax, shape is symmetrical, spinal alignment is in midline without
deformation. As we observed her breathing pattern is effortless. Chest skin turgor is
good. In auscultating the chest, we use symmetric zigzag procedure and ask our client
to take slow deep breaths through the mouth. Which results a vesicular and
bronchovesicular breath sounds. As we auscultate the anterior chest, there were
presence of brochovesicular and vesicular breath sounds. In assessing for the posterior
respiratory excursion, we place our thumb about the level of 10
th
rib our hand grasping
the lateral rib cage, as we position our hands we slide them medially in order to raise
loose skin folds between our thumbs and the clients spine. It results to a symmetrical
respiratory movement. For the tactile fremitus, we place our hands at the back of the
client we ask our client to say 99 while the client is speaking, we move our hands
downward. Tactile fremitus is found over the mainstem bronchi near clavicles as we
move our hands downward and outward the fremitus decreases. Bronchial breath
sounds is present during auscultation and absence of adventitious breath sounds like
wheezes and crackles.

XI- HEART
As we ausculate for our clients heart, precordium is normodynamic. In auscultation
for the aortic, pulmonic, tricuspid and apical heart sounds, it was all distinct and strong.
As we palpate using extreme caution the temporal, carotid, apical, brachial, radial,
popliteal, dorsalis pedis and posterior tibia, pulses are all strong and have symmetric
pulse volumes.

XII- BREAST
As we inspect the breast of our client in sitting position, size and symmetry are
equal; there is no presence of swelling and lesions. In our clients breast we have
observed that superficial veins becomes more prominent and has a linear stretch
marks. In inspecting the areola size is round, symmetrical, with a dark brown color and
no presence of discharges and lesions. As we palpate the breast outward, there are no
presence of tenderness and masses.

XIII- ABDOMEN




IX- GENITO-URINARY