General beat regular and normal. Breast Both breast are

General
Appearance

Well
oriented to time, place and person. Well conscious, co-operative, slightly anxiety
and fear, pallor and anemic.

We Will Write a Custom Essay Specifically
For You For Only $13.90/page!


order now

Vital
Sign
 

Pulse              : 106b/min
Respiration   : 24/min
Temperature : 37 degree celcius
BP                   :
90/50mmhg
Weight           : 42kg
Height                        : 5 feet

Nutritional
status

The
mother has gain average weight with respect to height.

Mental
state

Alert
response appreciably.

Personal
Hygiene

Seems
clear and wear clean cloths.

Head

Clean,
dry and smooth hair, no lice, no extra growth.

Ears

Normal
shape, no swollen glands, no valve discharge.

Eyes

No
discharge, no swollen, normal vision, normal eye movement.

Lips

Normal
lips, moist, no cracks.

Tongue

Pink,
no dehydration, moist.

Gums

No
swelling and no bleeding.

Skin

Slightly
pale, no redness, no any liaison.

Lymph
node

Not
visible and palpable.

Chest

Symmetric
shape and size of the chest, no shortness of breath, no any abnormal sound,
heart beat regular and normal.

Breast

Both
breast are symmetrical in shape and size. No lump found.

Arms
& Legs

Shape
and size normal, full range of motion, Edema + in ankle.

Abdomen

1)    Inspection
Ovoid shape, small in
size, no any scar, linea nigra present, no any visible dilated veins.
2)    Palpation
·        
Fundal palpation: Fundal height is
small then gestation.
·        
Pelvic palpation: On pelvic palpation
head is floating.
·        
Pelvic grip palpation: The head is floating.
3)    Auscultation
On auscultation FHS is
heard regular and 138bpm.

Genitalia

No
swelling, no redness, no any infection.

Reflexes

·        
Motor and sensory reflex – good.
·        
Corneal reflex – positive.
·        
Biceps reflex – positive.
·        
Triceps reflex – present.
·        
Brachio-radial reflex – both forearm
flex.
·        
Knee-jerk reflex – present.
·        
Planter reflex – present.
·        
Ankle reflex – present.

x

Hi!
I'm Homer!

Would you like to get a custom essay? How about receiving a customized one?

Check it out