uaLe of AssessmenL AugusL 12 2011

Genera| Survey
Cur paLlenL P A was wearlng a red shlrL and brown legglngs wlLh a red braceleL on her
lefL forearm and a blue braceleL on her rlghL forearm wearlng a blue necklace and vloleL
headband slLLlng on a bench awake coherenL and responslve Lo any sLlmull She ls noL ln any
form of resplraLory dlsLress 1he cllenL has a mesomorphlc body bullL She has a proporLlonal
and symmeLrlcal body bullL 1here were no body deformlLles noLed 1here were no body and
breaLh odor noLed 1he cllenL was very parLlclpaLlve durlng Lhe whole assessmenL 1he cllenL's
mood was approprlaLe Lo Lhe slLuaLlon 1he cllenL welghs 49 kg and has a helghL of 3 feeL Per
8ody Mass lndex ls 211

vl1AL SlCnS nC8MAL vl1AL SlCnS 8LSuL1S
1emperaLure 363 373 C 338 C afebrlle
PearL 8aLe 80 90 bpm 66 bpm rhyLhmlc
ulse 8aLe 80 90 bpm 63 bpm rhyLhmlc and wlLh +3
ampllLudenormal
8esplraLory 8aLe 16 20 cpm 22 cpm quleL and efforLless
8lood ressure 110/70 120/80 mmPg 110/80 mmPg normoLenslve

nead and Sku||

1he paLlenL has a normocephallc head Per skull ls rounded and has a symmeLrlcal
conLour 1here were no nodules masses and depresslons noLed upon palpaLlon Pls faclal
feaLures lncludlng Lhe nasolablal folds were symmeLrlcal and nelLher devlaLlons nor
abnormallLles were presenL She has absenL lnvolunLary movemenLs of her faclal muscles She
has symmeLrlcal faclal movemenLs Per faclal expresslon was approprlaLe Lo Lhe seLLlng 1he
cllenL has Lwo moles near Lhe rlghL eye She has a gray halr LhaL was equally dlsLrlbuLed 1here
were no dandruffs leslons lnfecLlons and lnfesLaLlons noLed durlng Lhe whole assessmenL Per
forehead ls furrowed wlLh wrlnkles Per head clrcumference ls 33 cm

Sk|n and Na||s

Skln ls sllghLly brown ln color and wlLh mlnuLe llver spoLs or brown spoLs boLh aL her
upper and lower exLremlLles measurlng Lo 8 mm aL her rlghL arm She has a senlle skln Lurgor
Per skln ls mlnlmally dry and equally normally warm Lo Louch She has a scar on her lefL fooL
due Lo an unrecalled lncldenL She has no leslons Lenderness sweaLlng and olllness ln her skln
1he cllenL has wrlnkled skln ln some areas speclflcally ln her armplL groln anLecublLal and
orblLal area Per nalls were pollshed wlLh green color manlcure and were well Lrlmmed nalls
were smooLh round wlLh 160 degrees nall base hard and Lhlck Surroundlng Llssues ln Lhe nalls
were lnLacL

Lyes

Lyebrows were evenly dlsLrlbuLed allgned have symmeLrlcal movemenLs and wlLh
whlLe halrs 1he eye llds were also lnLacL and symmeLrlcal wlLh no dlscharges and dlscoloraLlons
noLed upon lnspecLlon Lye lashes were curled ouLward when lnspecLed on her laLeral slde Per
eyes close symmeLrlcally wlLh nelLher paln nor dlfflculLy Lacrlmal ducL ls nelLher Lorn nor
swollen Cornea was clear upon lnspecLlon Per bulbar con[uncLlva was LransparenL and
palpebral con[uncLlva was pale ln color upon lnspecLlon 1he paLlenL's pupll slzes were round
symmeLrlcal and 2 mm ln dlameLer and brlskly reacLlve Lo llghL and accommodaLlon Per puplls
consLrlcLs wlLh llghL and when looklng aL near ob[ecLs and dllaLes ln Lhe dark and when looklng
aL far ob[ecLs Per lrls ls brown ln color 1he cllenL can mover her eyes from slde Lo slde up and
down and can roll lL wlLhouL dlfflculLy or paln felL She can read wlLhouL her eyeglasses buL can
read beLLer wlLh lLs supporL She has been uslng Lhese eyeglasses for already a year

Lars

Lars are unlform ln color as her faclal skln and are also symmeLrlcal ln slze 1here was no
cerumen or dlscharge noLed upon lnspecLlon of Lhe exLernal canal 1here was no foul odor
noLed on hls exLernal canal Aurlcles are free from wounds or leslons upon lnspecLlon and were
smooLh lnna recolls lmmedlaLely afLer foldlng 1he cllenL was able Lo repeaL Lhe words spoken
by Lhe sLudenL nurse from her behlnd wlLh a dlsLance of 60 cms She can also hear whlsper
words and Lhe Llcklng of Lhe waLch on boLh ears

Nose

1he nose was symmeLrlcal and unlform wlLh Lhe color of Lhe faclal skln no nasal flarlng
noLed durlng Lhe whole assessmenL no Lenderness leslons and masses noLed upon lnspecLlon
nasal sepLum ls ln mldllne and ls noL devlaLed or perforaLed Mucosa was plnklsh ln color Alr
moves freely on each nares when lL was covered one by one 1here were no dlscharges noLed
Pls fronLal and maxlllary slnuses were non Lender durlng palpaLlon

Mouth

1he llps were symmeLrlcal sllghLly brownlsh ln color and were dry wlLhouL cracks 1he
Longue was ln Lhe mldllne wlLh paplllae whlch vary ln slze from Lhe Llp Lo Lhe back molsL and
no devlaLlon and leslons were noLed uenLal carles and dlscoloraLlons of LeeLh were noLed upon
lnspecLlon 1he cllenL has 1 lnclssor 2 canlnes 2 premolars and no molar LeeLh ln her lower
mandlble and 1 premolar 2 canlne and 2 lnclssors ln her upper mandlble She has a LooLh decay
ln her 1 lnclssor of her lower mandlble and Lhe lefL 1 canlne of her upper mandlble 1he cllenL
does noL use any denLures 1he gums were plnklsh ln color and nonLender Per buccal mucosa
ls plnk smooLh and wlLhouL any leslons SofL and hard palaLe are plnklsh ln color and Lhere
were no leslons or swelllng noLed upon lnspecLlon 1he palaLlne Lonslls are plnk ln color and noL
enlarged 1he paLlenL ls able Lo chew and swallow Lhe food properly wlLhouL dlfflculLy or
paln 1he cllenL's uvula rlses whenever she says ah" no hallLhosls noLed nelLher hoarseness
and any dlsorder of speech noLed

Neck

Muscles are equal ln slze head ls locaLed aL Lhe mldllne 1here are no masses unusual
swelllng or pulsaLlons noLed 1he cllenL ls able Lo roLaLe her head flex and hyperexLend her
head 1he neck moves easlly wlLhouL any dlscomforL from slde Lo slde wlLh and wlLhouL
reslsLance 1rachea ls locaLed aL Lhe mldllne spaces are equal on boLh sldes 1hyrold gland ls
nelLher vlslble upon lnspecLlon nor enlarged lL ls wlLhouL nodules masses lrregularlLles or
brulLs 1he gland ascends durlng swallowlng Pls cervlcal lymph nodes are noL enlarged vlslble
and palpable 1he caroLld arLerles ls noL dlsLended

Chest and Lungs

ChesL ls symmeLrlcal wlLh an anLeroposLerlor dlameLer of approxlmaLely 12 1he splne
ls verLlcally allgned wlLh no Lenderness bulges or leslons noLed 1he rlghL and lefL shoulders are
allgned Per coasLal angle ls less Lhan 90 degrees Skln ls lnLacL and unlform ln color wlLh equal
LemperaLure ChesL wall ls lnLacL wlLh no Lenderness noLed upon palpaLlon lull and symmeLrlc
chesL expanslon noLed Lhumbs separaLe 3 cm whenever Lhe cllenL breaLhes ln 8reaLhlng ls
quleL and efforLless wlLh a resplraLory raLe of 22cpm eupnlc 1he vocal LacLlle fremlLus of Lhe
paLlenL ls equal LhroughouL Lhe lung flelds afLer she sald 99" 1here were no creplLaLlons
noLed uurlng percusslon resonance was noLed over her scapula and lung flaL along Lhe
rlbcage bones and dull over Lhe hearL and llver area 1here were no crackles wheezes rhonchl
or sLrldors noLed upon ausculLaLlon She has a chesL clrcumference of 89 cm

neart
olnL of maxlmum lmpulse ls besL heard aL Lhe lefL mld clavlcular llne 3Lh lnLercosLal
space no vlslble pulsaLlons ln her chesL area 1here were no bulglng heavy or LhrusLlng ln Lhe
precordlum upon palpaLlon of Lhe caroLld arLerles lL exhlblLed full pulsaLlons and remalns
same when cllenL breaLhes Lurns head and changes poslLlon from slLLlng Lo suplne PearL
sounds were dlsLlncL and regular PearL raLe ls normal and regular ln rhyLhm wlLh a hearL raLe
of 66 bpm 1here were no Lhrllls or murmur durlng ausculLaLlon 1he perlcardlal area was dull
upon percusslon and showed no slgns of Lenderness

8reast and Ax|||ae

8reasLs are symmeLrlcal equal ln slze and unlform ln color and LemperaLure 1he breasL
ls sllghLly sagglng 1here were no masses or Lenderness noLed CllenLs nlpples and areola are
unlform ln color and symmeLrlcal wlLh no Lenderness masses and nodules noLed nlpples are
nelLher lnverLed nor leLLlng ouL a dlscharge Palr ln axllla ls mlnlmal wlLh no Lenderness and
masses noLed Axlllary lymphnodes were noL palpable or Lender no body odor was noLed

Abdomen

AfLer Lhe bladder was empLled upon lnspecLlon Lhe abdomen ls flaL skln ls lnLacL wlLh
no leslons or rashes noLed 1he umblllcus ls ln Lhe hypogasLrlc reglon wlLhouL dlscharges or
leslons 1he abdomen ls unlform ln color and LemperaLure no Lenderness and masses were
noLed upon palpaLlon of Lhe 9 reglons When paLlenL Look a deep breaLh Lhere were no
evldence of enlargemenL of Lhe llver and spleen 1here were 13 bowel sounds per mlnuLe upon
ausculLaLlon wlLh Lhe normal growllng sound 1here were no rubs or brulLs CllenL verballzed
LhaL she usually has bowel movemenL every day wlLh a formed sLool uullness was noLed ln her
llver and Lympanlc sound ln her sLomach area upon llghL palpaLlon Lhere was no muscle
Lenslon and reslsLance Lenderness and superflclal masses or organ enlargemenL noLed 1he
cllenL has a senlle skln Lurgor buL does noL lndlcaLe any slgns of dehydraLlon upon deep
palpaLlon Lhere were no masses abdomlnal veln dlsLenLlon or Lenderness noLed Llver ls
palpable lngulnal and femoral lymph nodes are noL enlarged or Lender

Gen|toUr|nary

CllenL's publc halr ls evenly dlsLrlbuLed noL Lhlck and has a shape of an lnverLed
Lrlangle 1here were no leslons edema or nodules noLed 1here were no dlscharges or leslons
ln Lhe exLernal genlLalla Per perlneal area ls noL lnflamed swollen or wlLh any leslons Per
labla ma[or ls sagglng and wlLh wrlnkles 1here were no scars leslons enlarge lymph nodes
hernla or bulglng ln her groln Per anal sphlncLer ls darker compared Lo Lhe resL of Lhe skln of
her gluLeal area 1here were no lnflammaLlons skln leslons scars haemorrholds or decublLus
ulcers ln her gluLeal and anal area She usually urlnaLes 23 Llmes a day wlLhouL paln or
dlfflculLy

8ack and Upper and Lower Lxtrem|t|es

Per shoulders and arms are noL swelllng deformed aLrophled buL symmeLrlcal She
does noL complaln any paln upon Lhe roLaLlons of her [olnLs of her shoulder elbow and wrlsL
She can roLaLe exLend and flex her exLremlLles wlLhouL reslsLance or dlfflculLy She can flex
exLend suplnaLe and pronaLe her forearms wlLhouL any sLruggles Per hands and wrlsLs has no
mlsslng or deformed flngers no conLracLures swelllng redness pallor bone enlargemenLs
nodules aLrophy or Lremors emlnenL
She can easlly roLaLe her hlp [olnLs and Lhlghs wlLhouL paln and Lenderness 1here were
no deformlLles scars or slgns of ampuLaLlon Per legs and knees can easlly revolve wlLhouL
deformlLles edema or slgns of lnflammaLlon She has a scar on her lefL fooL due Lo an
unrecalled cause Per fooL has no slgns of deformlLles Lenderness and can easlly move Per
feeL ls darker ln color compared Lo her upper exLremlLles
Splne ls locaLed ln Lhe mldllne wlLhouL any devlaLlons noLed She has equal sLrengLh on
boLh sldes of her upper and lower exLremlLles upon assessmenL no deformlLles and
Lenderness on Lhe sLrucLures noLed CllenL has no nodules upon lnspecLlon 1he paLlenL can
move boLh of hls upper and lower exLremlLles freely wlLhouL paln and dlfflculLy

NLUkCLCGICAL ASSLSMLN1
I Cerebra| Iunct|on
A Menta| Status

Language aLlenL does noL have aphasla and dysarLhla she speaks uslng a normal volce Lone
wlLhouL dlfflculLles
Cr|entat|on 1he cllenL has Lhe ablllLy Lo recognlze some of Lhe sLaff of Creen Meadows She ls
noL orlenLed Lo Llme as evldenced by her verballzaLlon unsa na ba karon?!anuary naman aLa o
lebruary o March?" 1he cllenL ls orlenLed Lo place slnce she knows LhaL she ls ln uavao and
noL ln vlnLar uavao uel Sur
Memory 1he cllenL was able Lo remember lmmedlaLe memory such as when Lhe group asked
her whaL snack she aLe durlng Lhe group's program Powever she gave us false lnformaLlon
when Lhe group asked who Lhe person who lasL vlslLed her and responded lL was her son on
Lhe oLher hand Lhe charL revealed lL was her granddaughLer and daughLer ln law who vlslLed
her lasL week She has even denled LhaL her granddaughLers and her daughLerlnlaw have
never vlslLed her When asked who her besL frlend ls or someone she usually Lalks Lo ln Lhelr
bedroom she nelLher dlrecLly nor confldenLly says who lL ls neverLheless Lhe cllenL was able
Lo recall long Lerm memory such as hls blrLh daLe and place
Attent|on Span 1he paLlenL was aLLenLlve and does noL easlly geL dlsLracLed

8 Leve| of Consc|ousness

kLAC1IVL LLVLL SCALL AlerL 1
GLASCCW CCMA SCALL
Lye Cpenlng 4
1he response of Lhe paLlenL ls sponLaneous She lmmedlaLely noLlced us as we enLered Lhe
lnsLlLuLlon
verbal 8esponse 4
1he paLlenL was orlenLed place and person buL noL Lo Llme when assessed by Lhe sLudenL
nurses She responds confusedly
MoLor 8esponse 6
1he paLlenL obeys Lo verbal command as Lhe sLudenL nurses lnsLrucLed her Lo ralse her legs and
Lo grasp Lhe sLudenL nurses hands

8LS / CCS 1/14

ulLS
LefL 8rlsk
8lghL 8rlsk
PAnu C8l
LefL SLrong
8lghL SLrong
LLC MCvLMLn1
LefL SLrong
8lghL SLrong


II Cran|a| Nerves
C8AnlAL nL8vL SLnSC8?/MC1C8 lunC1lCn 8LSuL1
ClfacLory Sensory Smell 1he paLlenL's eyes
were covered and she
was sLlll able Lo
ldenLlfy Lhe smell of
[ulce and perfume
CpLlc Sensory vlslon and vlsual
llelds
1he paLlenL reads
small prlnLs ln Lhe
newspaper abouL 14
lnches away wlLhouL
any glasses buL can
read clearer wlLh lLs
supporL 1here were
no dlfflculLy of readlng
flne prlnLs as she was
able Lo read
nameplaLes of ours aL
a 12fL dlsLance
CculomoLor MoLor LCM MovemenL of
sphlncLer of pupll
movemenL of clllary
muscles of Lhe lens
1he paLlenL was able
Lo move her eyes on
Lhe slx cardlnal
dlrecLlons 1he pupll
slze was 2mm ln boLh
eyes and lL was brlskly
reacLlve Lo llghL and
accommodaLlon lL
consLrlcLs and dllaLes
ln response Lo llghL
and dlsLance
1rlgemlnal Sensory and MoLor SensaLlon of cornea
skln of face nasal
mucosa
When Lhe paLlenL
clenched her LeeLh
her Lemporal and
masseLer muscles felL
equally sLrong
aLlenL's [aw
movemenL was
normal 1he paLlenL
was able Lo bllnk as
Lhe coLLon came ln
conLacL wlLh Lhe
cornea 1he paLlenL
also felL Lhe coLLon as
lL came ln conLacL on
her lefL and rlghL
cheeks
Abducens MoLor LCM speclflcally
moves eyeballs
laLerally
1he paLlenL was able
Lo roLaLe her eyes ln a
clrcular manner from
Lop Lo lefL Lo boLLom
and Lo rlghL and back
Lo Lop as lnsLrucLed
laclal Sensory and MoLor symmeLrlcal faclal 1he paLlenL has
feaLures and
movemenL
symmeLrlcal faclal
feaLures when Lhe
sLudenL nurses
lnsLrucLed her Lo
smlle frown close
eyes and puff cheeks
vesLlbulocochlear Sensory Pearlng and 8alance uurlng Lhe lnLervlew
Lhe paLlenL was able
Lo hear Lhe sLudenL
nurses uslng a normal
volce conversaLlon
1he paLlenL ls able Lo
sLand and can
malnLaln balance
Clossopharyngeal Sensory and MoLor Swallowlng ablllLy
Longue movemenL
1he paLlenL has no
dlfflculLy of movlng
her Longue from lefL
Lo rlghL and was able
Lo swallow Lhe food
wlLhouL paln or
dlfflculLy
vagus Sensory and MoLor Swallowlng vocal cord
movemenL
1he sLudenL nurses
asked Lhe paLlenL Lo
open her mouLh
wldely Lhe sLudenL
nurses observed
durlng lnspecLlon LhaL
Lhe palaLe rlses and
uvula ralses ln Lhe
mldllne as Lhe paLlenL
says aaahhhh"
Accessory MoLor Pead movemenL
shrugglng of shoulders
1he paLlenL was able
Lo move her head Lo
hls lefL and rlghL
agalnsL reslsLance She
was also able Lo move
her head up and down
freely Per
sLernocleldomasLold
and Lrapezlus muscles
were equal ln slze
upon lnspecLlon and
palpaLlon She was
able Lo shrug our hand
reslsLance and ralsed
her shoulders
Pypoglossal MoLor roLruslon of Longue
from slde Lo slde up
and down
1he paLlenL was able
Lo move her Longue Lo
her lefL and rlghL up
and down and was
able Lo proLrude her
Longue








III Motor Iunct|on


1he paLlenL has a muscle sLrengLh of 3/3 aL Lhe rlghL upper and lower exLremlLles 3/3 aL Lhe
lefL upper and lower exLremeLles

C' Panlon nlchols Scale

3 normal muscle sLrengLh
4 lalr sLrengLh buL noL full sLrengLh agalnsL gravlLy and moderaLe amounL of reslsLance
3 MovemenL agalnsL gravlLy alone
2 MovemenL across Lhe body only buL noL overcome gravlLy
1 no movemenL buL wlLh palpable muscle conLracLlon
0 CompleLe paralysls