V.

PHYSICAL ASSESSMENT

General survey
Mr. LC appears attentively, conscious with slightly difficulty
breathing and he also has a good muscle tone. He has a good smell. He smiles
and gives appropriate facial expression. He has short attention span due to his
young age. He is noted with cough.

Vital signs
Body Temperature: 38
CR: 130 bpm
RR: 37 bpm

BODY PARTS METHODS FINDINGS ANALYSIS

SKIN Inspection • Fair skin complexion NORMAL

• No presence of any
NORMAL
lesions
• Smooth and soft
• Hot to touch
• Skin returns
immediately when
touched.

NAILS Inspection
• pale nail beds
• properly attached to
his nailbed
,
HEAD Inspection
• With moderate
 Fontanels Inspection molding

• Anterior fontanel has

a diamond shape
• Posterior fontanel has
EYES Inspection a triangular shape

• Symmetrical
 • Alert
• Clear sclera
 Eyebrows Inspection
• Iris black

Inspection • hair evenly distributed;

 Eyelashes symmetric in shape
Inspection
 Conjunctiva • curled slightly outward

Inspection • pale
NOSE

• color same as facial skin

symmetrical without any
Inspection discharge
EARS

• Symmetrical well
formed

• Parallel to outer
canthus of eye

• Infant responds to
MOUTH Inspection sounds

• Oral mucosa and lips are

pink in color
NECK • Palate are intact
Inspection
• Retains feeding

• Round
• Clavicles are intact
• Moves freely
THORACIC AND Inspection
LUNGS • Holds head midline
position

• Slightly labored breathing

• Nose breathers
HEART Auscultation • Lung sounds: crackles

• 130 bpm
ABDOMEN Inspection

• Umbilicus must be
sunken, centrally located
• Pinkish
• Cylindrical
• Symmetrical
Auscultation
• No bruits
• No friction rubs
Palpation • No venous hums

• Liver border: 3 cm below

costal margin
• Splenic border: 3 cm
below costal margin
GENITOURINARY Inspection

• No discharge
MASCULO- Inspection • Smooth
SKELETAL

• Extremities resist
NEUROLOGIC Inspection when extended

• Alert when awake

• Response in certain
stimulus

SUMMARY:

Based on the head to toe assessment done by different physical

assessment methods to Patient LC, 7 months old, almost normal findings in his
parts of his body but

Cranial Nerve I (Olfactory)

After assessing patency of both nares, have client close eyes, obstruct one nare, and sniff.
Use common, easily identifiable substances such as coffee, toothpaste, orange, vanilla,
soap, or peppermint. Use different substances for each side. Bilateral decreased sense of
smell occurs with age, tobacco smoking, allergic rhinitis, cocaine use. Unilateral loss of
sense of smell (neurologic anosmia) can indicate a frontal lobe lesion.

Cranial Nerve II (Optic)

Check visual acuity (have the patient read newspaper print) and visual fields for each eye.
Unilateral blindness can indicate a lesion or pressure in the globe or optic nerve. Loss of
the same half of the visual field in both eyes (homonymous hemianopsia) can indicate a
lesion of the opposite side optic tract as in a CVA.

Cranial Nerve III (Oculomotor)

Assess pupil size and light reflex. A unilaterally dilated pupil with unilateral absent light
reflex and/or if the eye will not turn upwards could indicate an internal carotid aneurysm
or uncal herniation with increased intracranial pressure.

Cranial Nerve IV (Trochlear) and Cranial Nerve VI (Abducens)

Have patient turn eyes downward, temporally, and nasally. If the eyes will not do this the
patient may have a fracture of the eye orbit or a brain stem tumor. (Note: Cranial Nerves
III, IV, and VI are examined together because they control eyelid elevation, eye
movement, and pupillary constriction.)

Cranial Nerve V (Trigeminal)

Motor – Palpate jaws and temples while patient clenches teeth.

Sensory – Have patient close eyes, touch cotton ball to all areas of face.

Unilateral deficit seen with trauma and tumors.

Cranial Nerve VII (Facial)

Motor

Check symmetry and mobility of face by having patient frown, close eyes, lift eyebrows,
and puff cheeks.

Sensory Asses the patient’s ability to identify taste (sugar, salt, lemon juice)

An asymmetrical deficit can be found in trauma, Bell’s palsy, CVA, tumor, and
inflammation.
Cranial Nerve VIII (Acoustic or Vestibulocochlear)

This tests hearing acuity. Impairment indicates inflammation or occlusion of the ear
canal, drug toxicity, or a possible tumor.

Cranial Nerve IX (Glossopharyngeal) and X (Vagus)

Motor

Depress the tongue with a tongue blade and have the patient say “ahh” or yawn. Uvula
and soft palate should rise. Gag reflex should be present and the voice should sound
smooth.

Deficits can indicate a brain stem tumor or neck injury.

Cranial Nerve XI (Spinal Accessory)

Have the patient rotate the head and shrug shoulders against resistance. If the patient is
unable to do this it may indicate a neck injury.

Cranial Nerve XII (Hypoglossal)

Motor

Assess tongue control.

Wasting of the tongue, deviation to one side, tremors, and an inability to distinctly say
l,t,d,n sounds can indicate a lower or upper motor neuron lesion.

Reflex Testing

When you strike a slightly stretched tendon with a reflex hammer, a simple muscle
contraction occurs. What kind of information do deep tendon reflexes (DTRs) give the
examiner? DTRs assist with evaluation of lower motor neurons and fibers. For example,
if the patient’s biceps reflex is normal, you know that the lower motor neurons and fibers
at levels C5 and C6 are intact.

There are five reflexes to check which include:

Biceps: With the patient sitting, flex his arm at the elbow and rest his forearm on his
thigh with the palm up. Place your thumb firmly on the biceps tendon in the antecubital
fossa. Strike your thumb with the hammer. The elbow and forearm should flex, and the
biceps muscle should contract.
Triceps: The triceps tendon is tested with the patient’s arm flexed at a 90° angle.
Supporting the arm with your hand, strike the triceps tendon on the posterior arm just
above the elbow. The tendon should contract and the elbow extend.

Brachioradialis: Have the patient rest his slightly flexed arm on his lap with the palm
facing downward. Strike the posterior arm about two inches above the wrist on the thumb
side. The forearm should rotate laterally and the palm turn upward.

Patellar: Dangle the patient’s legs over the side of the bed. Place your hand on the
patient’s thigh and strike the distal patellar tendon just below the kneecap. (If the patient
must remain supine, flex each leg to a 45° angle and place your dominant hand behind his
knee to support it.) The normal response is contraction of the quadriceps muscle with
extension of the knee.

Achilles: Have the patient dorsiflex (point downward) his foot slightly and lightly tap the
Achilles’s tendon on the posterior ankle area. A slight jerking of the foot should be seen.

To assess deep tendon reflexes:

• Encourage the patient to relax the arm or leg being tested.

• Position the arm or leg so the appropriate tendon is slightly stretched.
• Hold the reflex hammer lightly and swing it freely in an arc.
• Strike the tendon with a brisk downward stroke, then lift up on the hammer
immediately. When learning to perform DTRs, many people either tap too lightly
or they strike firmly but leave the hammer on the tendon which reduces the
response.
• Be sure to compare responses from one side to the other.
• Grade the reflexes in the following manner:

4+; Hyperactive; Often pathologic; may be associated with disease of the cerebral cortex,
brain stem, and spinal cord. 3+; Brisker than normal; Not necessarily pathologic. 2+;
Normal 1+; Diminished; May be normal 0; Absent; Pathologic; associated with both
upper and lower motor neuron disease or injury.

A patient with multiple sclerosis might have hyperactive reflexes, while areflexia
(absence of reflexes) can appear in Guillain-Barr? syndrome. Depressed or hyperactive
reflexes can also signal an electrolyte imbalance.

Motor System Assessment

Assessment of the motor system includes evaluation of bilateral muscle strength and
coordination and balance tests. Be sure to assess bilaterally and compare findings.

Muscle Strength
Examine the arm and leg muscles looking for atrophy and abnormal movements such as
tremors. For a quick check of muscle tone, perform passive range of motion exercises and
note any resistance. Next, instruct the patient to bend the forearm up at the elbow
(flexion) while you hold the patient’s wrist exerting a slight downward pressure. This
tests the strength of the biceps. Then test the triceps by having the patient extend his arm
while you push against his wrist. Hand grasps should also be assessed. Ensure that the
patient follows instructions to release the hand when assessing grip strength. In some
cases, gripping the examiner’s hands is almost reflex while being able to release the hand
grasp on command is more important.

Assess upper leg muscle strength of a bed patient by having him flex his hip and knee so
that the knee is about 8 inches off the bed. Tell the patient to maintain this position while
you attempt to push down against the thigh. Standing at the foot of the bed, test lower leg
and foot muscle strength by having the patient push his foot against your hand, then have
him pull it up against your hand.

Coordination and Balance Tests

Coordination can be checked by having the patient close the eyes and touch the finger to
the nose. Coordination can also be assessed by having the patient perform rapid
alternating movements (RAMs). The patient is instructed to pat his upper thigh with the
same side hand, alternately patting with the palm and the back of the hand as quickly as
possible. Repeat with both hands. These tests will help you evaluate coordination and
detect intentional tremors.

If your patient is confined to bed, you won’t be able to test his balance. However, if he
can stand beside the bed, you can perform the Romberg test for balance. With the feet
together and arms to the sides as if standing at attention, have the patient maintain this
position for about 30 seconds with the eyes open then another 30 seconds with his eyes
closed. Stay close to the patient in case he starts to fall. It is normal to see minimal
swaying. In some illnesses, vision compensates for a sensory loss. If the patient has a
cerebellar disease, he may be able to maintain his balance with the eyes open, but not
with them closed.

Sensory System Assessment

Follow these steps when testing the patient’s sensory system:

o Instruct the patient to keep his eyes closed during all the tests. o Compare one side with
the other, noting whether sensory perception is bilateral. o If you detect an area of
increase or decreased sensation, mark it with a water-soluble marker and note which
peripheral nerves carry sensation to the area.

The assessment of the sensory system includes the evaluation of Cranial Nerve V, the
trigeminal nerve (see facial evaluation). You will also be testing the patient’s ability to
detect superficial pain. If the pain sensation is present, you do not have to test for
temperature. To test for pain, have the patient close his eyes and let you know when you
are touching a sterile needle to his skin. Lightly touch the proximal and distal aspects of
the arms and legs with the needle.

Age Related Changes of the Neurological System

Decreased sensitivity to outside stimuli slows response time. Older people may not
realize the air temperature is too cold or too warm. Vision is affected by aging as the lens
of the eye begins to stiffen and lose water, compromising its ability to change shape for
focus. Pupils become smaller, decreasing the amount of light reaching the retina, so an
older person may find it hard to see in dim light. Hearing decreases because of natural or
mechanical means. By the time a person reaches age 80, brain weight may be as much as
10% less than it was, blood flow to the brain decreases, and brain metabolism slows.

Behavior
The baby is sitting comfortably in his mother’s lap. He is socially aware, inquisitive and
readily responds to visual objects and sounds. He smiles, laughs, and jabbers. At this age
a baby will start to make repetitive speech sounds that are nonspecific such as da, ma, or
ba.

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Cranial Nerves
The baby is able to visually track an object throughout the horizontal and vertical planes.
An interesting or colorful object is most helpful. To test visual fields, have the baby focus
on an object in front of him and then bring a second object from behind him until he sees
the object in his peripheral vision. He should turn toward the new object. Saccadic eye
movements are tested by using interesting toys and sounds and watching the eyes jump
from object to object. To test hearing, produce a sound out of the baby’s sight and then
watch the baby turn and localize the sound. Facial movements are noted as the baby
smiles or cries.
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Motor - Sitting
Independent sitting is accomplished by 6 to 8 months. This baby has good sitting posture
(head erect and spine straight) and has enough stability to reach for objects with both
hands. He even stretches to obtain an object without loosing his balance.

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Motor - Hand
The baby is able to reach out and pick up an object and bring it to the midline, usually to
his mouth. He reaches equally well with either hand. Hand preference before one year of
age is always abnormal and indicates a motor deficit in the non-preferred hand.

At this age, the baby is able to transfer an object from hand to hand. By 5 to 6 months, a
baby grasps objects that are the size of a cube. An ulnar or palmer grasp is a raking
motion with the fingers trapping the object against the palm.

The next stage of hand development is to use the thumb in concert with the fingers to
grasp an object. This is called a whole hand grasp. The baby is starting to use the thumb
so has developed a whole hand grasp. A thumb-finger pincer grasp develops at 7 to 9
months.

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Motor - Tone
Tone is assessed for the upper and lower extremities by passive range of motion when the
baby is cooperative. Distraction is a great way to get that cooperation. Babies at this age
have found their feet and can suck on their toes. On passive range of motion, the lower
extremity should be flexible enough to bring the foot to the baby’s mouth. There
shouldn’t be any ankle clonus.

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Motor - Traction
On traction, which is pulling to a sitting position, the baby has good head and trunk
control. The head and shoulders are flexed forward and the arms are flexed. The baby
actively helps himself to get to the sitting position by pulling with the arms. Also notice
that the legs are flexed at the hips and are off the mat as the baby pulls himself to sitting.
On being laid back down to the supine position, the baby doesn’t flop back, but is able to
control the lowering of his head and trunk to the mat.

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Position - Prone
In the prone position, the baby brings his chest all the way off the mat and supports his
weight on his hands, not his forearms. He works for toys out of his reach. He is close to
crawling. He can roll over from front to back and back to front.

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Reflexes - Deep Tendon Reflexes
It is hard to get the baby relaxed and cooperative enough to get the limb in the optimal
position for obtaining deep tendon reflexes. At this age, all the deep tendon reflexes
tested in an adult exam should be obtainable.

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Reflexes - Plantar Reflex

There is still a lot of plantar grasp at this age as well as withdrawal, which makes testing
for the plantar response difficult at this age. The toes are still up going until one year of
age. The most useful finding at this age is if there is asymmetry in the toe findings.

Plantar reflexes; small object placed beneath the toes

Tonic neck reflexes

lying on his back turn his to the right side