May Gasco is a 26-year-old married woman who presented to the emergency room with complaints of fatigue, excessive thirst, and frequent urination for 2 days. She has been diagnosed with gestational diabetes mellitus. On examination, she appeared pale with linea nigra present. Vital signs were stable. A review of systems was otherwise unremarkable except for blurry vision related to her diabetes. Her past medical and family histories were noncontributory.

1. PHYSICAL ASSESSMENT
A. SOCIOCULTURAL ASSESSMENT
I. Identifying data
Name: May Gasco Sex: Female Age: 26 years old Race/Ethnicity: N/A
Date of admission/or first contact: January 27, 2022 Referral source: N/A
Previous occupation or present employer: N/A
II. Environment
a. Describe neighborhood and geographical area in which you reside. What about it was important to you? – N/A
b. Describe your current or previous home and arrangement of space: What health hazards are or were present? –
N/A
c. What transportation facilities do or did you use? – N/A
d. What leisure activities or recreation do you pursue? Where? With whom? – Sometimes going to the beach with
my husband and also eating while watching tv.
e. What was or is the environment at work? What health hazards were or are present? – N/A
III. Socioeconomic Level and Life-Style
a. How would you describe your socioeconomic level and life-style? How do you think these have affected your
health? – N/A
b. How has your health status affected your life-style? – It affects me a lot to the fact that I can’t do work
properly, my body just tends to be weary and fatigue, I feel like I don’t have a lot of energy.
c. What changes do you expect in your life-style as a result of growing older? Illness, hospitalization, admission to
hospital? – N/A
d. What special practices or foods do you consider essential? – I used to eat any foods but my favorite one would
be chocolate and I also love drinking softdrinks.
IV. Family Patterns
a. Marital status. – Married
b. Children. – N/A
c. Other important members of the family. – Parents of patient D.
d. Who resides in the home with you? – Husband, Mr. bong.
e. What is the usual daily living pattern in your family? – N/A
f. What family events are important? – Recreation like watching tv or dating because I do love do bond with my
husband.
g. What rituals are important in your family? – N/A
h. How do daily living pattern and rituals affect your health? – N/A

2. V. Family Functions and Interactions:
a. What is your role in the family? – Mother and a Wife
b. How are decisions made in the family? – N/A
c. Who helps provide for the family? – Husband, he works as a Policeman in our city.
d. Who has the responsibility for the various family tasks? – N/A
e. What are your special concerns in your family? – N/A
V. Religious Practices
a. What church or religious denomination do you belong to as a member? – N/A
b. Are you active in that church? – N/A
c. Are there special beliefs that you adhere to? How do these beliefs affect your health? – N/A
d. How do you see your relationship to God during this time period? What affect does God have on your health or
illness? – N/A
e. If you do not prescribe to a particular religion, what are your basic beliefs and values? – N/A
f. How do these beliefs and values affect your health or illness? – N/A
g. What can the nurse do to assist you in practicing your religion or beliefs during your stay at this center? – N/A
VI. Memberships
a. What groups/organizations in the community to you belong to? – N/A
b. What is your role in these groups? – N/A
c. How much satisfaction do you get from group activities? – N/A
VII. Personal Values (consider expressedideal vs. real)
a. What are your ideas about the following:
Man and the environment relationship? – N/A
Privacy vs. group interaction (being with others)? – N/A
Possessions (personal vs. shared)? – N/A
b. Time orientation:
Do you like to have things done promptly? – N/A
Do you rely on past experiences primarily? – N/A
Do you like to plan ahead into the future? – N/A
How do you feel if you know that you or someone else is going to be late to an event? – N/A
c. Work or Activity – Leisure Orientation:
How much time do you spend in work tasks daily? – Sometimes like 2 to 3 tasks.
Do you prefer to be busy? Sitting and thinking; Reading or relaxing? – Reading books.
What do you do to relax? – N/A
How much time do you spend in leisure daily? – N/A

3. d. Attitude toward change:
How do you feel when you hear the word change? – N/A
How often do you make/have you made changes in your life? – N/A
What changes would you like to make in yourself? In others? In the environment? – N/A
e. Education:
Level of school achievement? – N/A
How important is education to you? – N/A
What do you consider necessary for achievement? – N/A
f. Health-Illness Value or Definitions:
When do you consider yourself or members of your family healthy? – N/A
When do you consider them ill? – N/A
What do you do when you or members of your family become ill? – N/A
What customs, special practices or rituals do you and your family engage in to keep healthy? – N/A
Do you and your family have any specific beliefs or observe any specific traditions concerning health? – N/A
The Health History Includes the Following Data:
I. Identifying Data:
Name: May Gasco Sex: Female Address: N/A
Race/Ethnicity: N/A Age: 26 years old
Marital Status: N/A If widowed, when? – N/A
Occupation: If retired, date? – N/A
Reasonfor contacting health agency: – N/A
I
I
. I. A concise statement of the Chief Complaint and its Duration
Patient D has arrived on the hospital with a chief complaint of fatigue, polydipsia, polyuria,
polyphagia, and yeast infection. She claimed to experience those for 2 days.

4. I
I
I
. . Concise chronological description: Present health status and present illness
 Patient D is a 26 years old woman, who came in the emergency room with chief
complaint of fatigue, excessive thirst, and increased-frequent urination.
 The patient has a gestational diabetes mellitus (GDM) that made her more distress and
easily to get fatigue.
I
V
. V. Past Medical History
 N/A
(Beginning as far back as the person can remember and continuing up to the time when he
considered himself to be in good health.)
Childhood: – N/A
Medical: – N/A
Surgical, including accidents: – N/A
Psychiatric: – N/A
Obstetrical: Number/outcomes of pregnancies, abnormalities or complications. – N/A
Hospitalizations: – N/A
Include names of hospitals, dates, attending physicians and problems. – N/A
Previous routine or periodic examinations. – N/A
Exposure to known cause of illness: – N/A
Travel in foreign countries, exposure to toxic substances. – N/A
Allergies – to what and what reactions: – N/A
V
. Personal and Social History
Childhood: – N/A
Birth (when & where), family group, education, environment, problems: – N/A
Adulthood – employment history, military service: – N/A
Sexual & marital history – marital status, sexual activity, children: Married.
Present life-style:
Descriptions of home, occupation, family life, affiliations, habits: – N/A
Tobacco: Type – cigarettes, cigars, pipe, chewing, snuff. Age at which began use. Current level
of usage. – N/A
Beverages: Coffee, tea, cola. – Soft drinks like coke.

5. 20
Alcohol: Average daily use or weekly consumption. – N/A
Drugs: Drug use – including legal and illegal drugs, prescription drugs, over-the-counter drugs. –
N/A
Present schedule and dosage – Sleeping pills, aspirin, weight-control drugs, antihistamines, folk
remedies, laxatives, enemas, vitamins. – N/A
Personal Habits: Sleep, working hours, travel, vacation, hobby or leisure activities
Nutrition and hydration (sample one day’s diet and fluid intake). Special diet needs. –
Watching Tv and eating.
Family history:
Health status of close relatives: – N/A
Presence of specific diseases: Diabetes, tuberculosis, cancer, mental illness, illness similar to the
patient’s present illness: – N/A
Family tree: Include grandparents, parents, siblings, children – N/A
Religious practices: Denomination, church location, pastor, usual attendance. – N/A
Do you anticipate any specific spiritual/religious needs? If so, what? – N/A
THE REVIEW OF SYSTEMS AND THE PHYSICAL EXAMINATION
Includes the Following Data:
I
. . Measurement of Vital Signs
Weight:165 lbs. Height: 5 feet and
2 inches
Pulse: 85 Bpm
Temp: 36.4 °C Respiration: 26
Cpm
BP: 130/80 mmHg
I
I
. I. General Appearance
a
. . . HISTORY OF ANY WEAKNESS: The patient gained weight from two to four
pounds during to her first trimester of pregnancy. In second trimester the patient
gained 11 to 13 pounds.
b. SKIN: Color, temperature, turgor, moisture, pigment changes, bruises, pressure areas,
decubitus, lesions, rashes and scars (location), dryness, texture, appearance of nails, size and
shape of fingers (clubbing), use of hair dyes or other agents. – Pallor is noted. Presence of
Linea nigra.
HEAD: History of headache, head injury, dizziness, syncope. – N/A
b
. EXAM:
Skull – deformities – N/A
Scalp – scaling – N/A
Hair – color, baldness, parasites – N/A
Face – expression, edema, muscle tics, paralysis – N/A

6. 21
f. EYES: History of pain, use of glasses, last change in refraction, diplopia, infection,
glaucoma, - Experience blurry vision due to the gestational diabetes.
cataract. – N/A
Vision – near, distant and peripheral – N/A
Pupils – reaction to light and accommodation, equality of size – N/A
Condition of lids, conjunctiva and sclera – movements, the expression, presence of
discharge – N/A
f. EARS: History of earaches, hearing loss, use of hearing aid, presence of tinnitus, vertigo,
discharge, infection, pain. – N/A
External – auditory meatus, tympanic membrane, general appearance – N/A
Hearing – distance whispered word heard – N/A
g. NOSE:
History of sinus pain, epistaxis, obstruction, discharge, postnasal drip, colds, sneezing. –
N/A
External – size, shape, smell, difficulty in breathing, discharge– N/A
Internal – patency, polyps, septal deviation, others. – N/A
h. MOUTH: History of toothache, recent extractions, soreness or bleeding of lips, gums, mouth,
tongue or throat, disturbance of taste, thirst, hoarseness, tonsillectomy. – N/A
Lips – pallor, cyanosis, lesions, dryness – N/A
Teeth – natural, state of repair, dentures. – N/A
Gums – bleeding, retracted, color, hypertrophic. – N/A
Tongue – color, size, deviation, hydration, lesions, tremors, paralysis. – N/A
Pharynx – motion of palate, uvula, tonsils, gag reflex, posterior pharynx-hoarseness,
difficulty speaking or swallowing, ulcerations, inflammation. – N/A
i. NECK: History of pain, limitation of motion, thyroid enlargement. – N/A
General – stiffness, R.O.M., tenderness, veins, pulses, bruits. –
Darkening of neck due to gestational diabetes mellitus.
Thyroid – enlargement, nodules, tenderness. – N/A
Lymph glands – size, consistency, tenderness. – N/A
j. THORAX: History of pain, breast lumps, discharge or operations. – N/A
Chest – size, shape and movements. – N/A
Breasts – nipple discharge, areola, contour, symmetry, masses (size, location, shape,
consistency, fixation), skin ulceration, axillary nodes. – N/A
k. HEART: History of pain or distress, palpitations, dyspnea (relate to effort), orthophea,
paroxysmal nocturnal dyspnea, edema, nocturia, cyanosis, heart murmur, rheumatic fever,
hypertension, coronary artery disease, anemia, last EKG. – N/A
Inspection:
Apex beat, relation to midclavicular or midsternal line. – N/A
Other pulsations. – N/A
Palpation:
Size, vigor of apex beat. – N/A
Left sterna lift, epigastric palpation, thrills. – N/A

7. 22
Percussion:
Distance of dullness from midsternal line in left second to sixth or seventh interspace. –
N/A
Auscultation:
Quality and intensity of S1 and S2 in each valve area. – N/A
Splitting. – N/A
Extra sounds – S3 and S4. – N/A
Murmur – location, radiation, systolic or diastolic, intensity, frequency, character-
crescendo, decrescendo, holosystolic. – N/A
l. LUNGS: History of pain, cough, sputum (character, amount), hemoptysis, wheezing, asthma,
shortness of breath, bronchitis, pneumonia, TB, or contact with, date of last x-ray or skin test and
the results of these. – N/A
Inspection:
Breathing pattern. – N/A
Symmetry. – N/A
Venous pattern. – N/A
Palpation:
Vocal fremitus. – N/A
Use of accessory muscles. – N/A
Percussion: – N/A
Location by inter-space dullness, flatness, hyperresonance, or tympany. – N/A
Auscultation:
Type of breath sounds – vesicular, bronchial, or bronchovesicular. – N/A
Adventitious sounds – rales, cavernous breathing, asthmatic breathing, friction rub. –
N/A
Vocal resonance – bronchophony. – N/A
m. ABDOMEN: History of appetite, food intolerance, dysphagia, heartburn, pain or distress
after eating, colic, jaundice, belching, nausea, vomiting, hematemesis, flatulence, character and
color of stools, any change in bowel habits, rectal conditions, ulcer, gallbladder disease, colitis,
hepatitis, appendicitis, parasites, hernia. – The patient has a condition of polyphagia due to
Gestational Diabetes Mellitus. And claimed to experienced nausea and vomiting.
Inspection:
Distention. – N/A
Masses. – N/A
Peristalsis (visible). – N/A
Palpation:
Tenderness of light or deep palpation. – N/A
Masses (location, consistency, mobility, nodularity). – N/A
Rigidity. – N/A
Organ outlines (liver, spleen). – N/A

8. 23
Percussion:
Abdominal distension (air or ascites). – N/A
Bladder distension. – N/A
Auscultation:
Bowel sounds. – N/A
Bruits. – N/A
n. EXTREMITIES AND BACK: History of intermittent claudication, varicose veins,
thrombophlebitis, joint pain, stiffness, swelling, arthritis, gout, bursitis, flat feet, infection,
fracture, muscle pain, cramps; assistance devices utilized (prostheses, cane, crutches, walker,
wheelchair). – N/A
Blood vessels – pulse veins. – N/A
Joints – tenderness, deformities, crepitation, range of motion. – N/A
Edema – location, pitting, discoloration. – N/A
Reflexes. – N/A
Sensation – pain and temperature, vibration position. N/A
Muscular function – standing on toes, strength of movement. – N/A
Gait and stance – walking, standing with eyes closed. – Decrease in step when walking due to her
condition and weight.
Back – pain (location and radiation, especially to extremities), stiffness, limitation of
movement. – Experience body ache specifically in the back and lower extremities.
o. GENITOURINARY: History of urinary tract – renal colic, frequency, nocturia, polyuria,
oliguria, hesitancy, urgency, dysuria, narrowing of stream, dribbling, incontinence, hematuria,
albuminuria, pyuria, kidney disease, facial edema, renal stone, cystoscopy; genital (male) –
testicular pain, scrotal change, nodules in scrotum; genital (female) – menstrual history, vaginal
bleeding or discharge, menopause and associated symptoms, date of last PAP smear, venereal
disease – gonorrhea or syphilis (note date, treatment, complications); sexual – drive, activity,
pleasure, discomfort, impotence. – The patient has experienced polyuria due to her
gestational diabetes mellitus.
Examination of the male genito – Urinary System:
Penis– N/A
Scrotum – size, symmetry, consistency, tenderness, masses, atrophy. – N/A
Inguinal region – pulses, lymph glands, hernia, parasites. – N/A
Character of urine – presence of indwelling catheter, date changed. – N/A

9. 24
Examination of the female reproductive system:
External genitalia. –
Presence of yeast
infection because of the
gestational diabetes
mellitus that causes the
itchiness and burning
sensation on the vagina.
Vulva – ulceration. –
Presence of yeast
infection because of the
gestational diabetes
mellitus that causes the
itchiness and burning
sensation on the vagina.
+ Urethra – discharge –
N/A
Pelvic relaxation – cystocele, rectocele, prolapse uterus (degree). – N/A
Internal genitalia. – N/A
Speculum exam of vagina (discharge, ulcerations, irregularities). – N/A
Cervix (ulceration, irregularity), PAP smear. – N/A
Examination of the rectum:
External inspection - hemorrhoids, perianal skin, pilonidal cyst. – N/A
Internal palpation – sphincter tonicity, abscess, prostate enlargement, rectal masses,
impaction. – N/A
CENTRAL NERVOUS SYSTEM:
General history – syncope, loss of consciousness, convulsions, meningitis,
encephalitis, stroke. – N/A
Mentative – aphasia (describe), emotional status, mood, orientation, memory, change in
sleep pattern, psychiatric illness. – N/A
Motor – tremor, weakness, paralysis (describe involvement), clumsiness of movement. –
N/A
Sensory – neurological pain, reduced sensation, paresthesia. – N/A
q. HEMATOPOIETIC: Bleeding tendencies; of skin or mucous membranes; anemia and
treatments, blood type, transfusions, any reactions; blood dyscrasias, exposure to toxic agents or
radiation. – N/A
r. ENDOCRINE: History of nutrition and growth; thyroid function – (changes in skin,
relationship of appetite to weight, nervousness, tremors, thyroid medications), diabetes or its

10. 25
symptoms, hirsutism, secondary sex characteristics, hormone therapy. – Presence of
gestational diabetes mellitus with the sign and symptoms of darkness of the neck,
fatigue, frequent urination, increased thirst, and yeast infection.
Activities of Daily Living Survey
Independent-Needs assistance, describe type of assistance Needed-Dependent
Bathing (Yes) Any Comments (No)
Dressing (Yes) Any Comments (No)
Toileting (Yes) Any Comments (No)
Feeding (Yes) Any Comments (No)
Transferring (Yes) Any Comments (No)
Ambulating (Yes) Any Comments (No)
Turning in Bed (Yes) Any Comments (No)