nl_e17

GENERAL PHYSICAL EXAMINATION: PERTINENT PHYSICAL FINDINGS/
PHYSICAL INJURIES - continued
GENERAL PHYSICAL EXAMINATION
HEIGHT WEIGHT
GENERAL SURVEY
MENTAL STATUS
PERTINENT
PHYSICAL
FINDINGS/PHYSICAL
INJURIES
Include if possible:
� Nutritional status (optional)
� Ambulant/non-ambulant
� Respiratory distress/not in respiratory distress
� Other comments
Include if possible:
� Orientation as to time, place, person
� Consciousness, demeanor
� Developmental delay or mental retardation?
Include if possible:
� Injuries on the body
� Description of breasts
� Pregnancy-related findings 10
� Other abnormalities
10. Pregnancy-Related Findings
If the patient is pregnant, evaluate the pregnancy according to the following criteria:
• Enlarged abdomen (measure fundic height)
• Presence of fetal heart tone (FHT) (record rate and location)
• Presence of fetal movement
• Gravity
• Parity
• Date of last menstruation
Example: abdomen globularly enlarged with FHT heard in right lower quadrant, and fetal movement
appreciated in left lower quadrant.
Estimation of the age of gestation may be based on the following:
• Date of last menstruation
• Onset of fetal movement
• Fundic height
• Ultrasound results
Pregnancy tests and their results should be recorded under the section “Diagnostics and Evidence
Gathering.”