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PRESENT STATE

PHYSICAL EXAMINATION
Day 1: September 16, 2015 (1:15
pm)
GENERAL APPEARANCE: Seen
patient on the bed awake, alert,
responsive, and coherent with ISA
on his left arm, with the following
vital signs:
BP=130/70mmHg
PR=102bpm
RR=36cpm
Temperature=37.1C/axilla
ANTHROPOMETRIC
MEASUREMENTS:
Weight: 47kg (103.4lbs)
Height: 46 (1.39m)
BMI: 24.32 (overweight)
IBW: 42.7kg (94 lbs)
BMI Categories:
Underweight = <18.5
Normal weight = 18.524.9
Overweight = 2529.9
Obesity = BMI of 30 or greater
SKIN: Dark brown, evenly colored
skin tone. Skin is dry and warm. Skin
is thin with calluses noted on plantar
surface of both feet. Skin pinches
easily and immediately return to its
original position. Hematomas 15 mm
in diameter are seen on both upper
and lower extremities due to
previous IV injection site. With ISA
on his left hand.

SCALP&HAIR: Hair is black, clean,


slightly oily, and smooth and firm
without parasites /lice infestations
noted. Scalp is clean and dry. Even,
prominent fine hair on arms, hands,
thigh and legs.
NAILS: Upper and lower extremities
has transparent nail with pinkish nail
beds. Nails are round with 160 nail
base. Hard, immobile, smooth and
firm nail plate is firmly attached to
nail bed. Fingernails are long with
black-dirt deposits.
HEAD & FACE: Symmetric, round,
erect and in midline. Hard and
smooth without lesions or lumps.
Head is still and upright without
abnormal facial movement.
Temporomandibular joint has no
swelling or tenderness, mouth opens
and closes fully.
EYES: Eyeballs are symmetrically
aligned in sockets without protruding
or sinking. Eyebrows are the same
with hair color, symmetric and
evenly distributed. Lid margins are
moist and pink. Lashes are long,
evenly spaced and curled outward.
Bulbar conjunctiva is clear, moist
and smooth with tiny vessels visible.
Sclerae is white. Palpebral
conjunctivae are pink, moist and free
from swelling and lesions. Cornea is
transparent, moist and without
opacities. Lens are clear. Pupils are
equally round and reactive to light

and accommodation (PERRLA).


Positive corneal light reflex,
reflections of light noted at same
spot on both eyes. Full extraocular
movements. Readssome writings on
the notebook within 12-14 inches
without difficulty. Client was able to
read out bed number illustrations
located at other end of the ward out
loud without squinting or difficulty.
EARS: Equal in size bilaterally.
Pinna is in line with lateral canthus
of both eyes. External ears are
smooth without lesions, color
consistent with the facial color and
no discharges noted. Small amount
of moist, yellow cerumen was noted
on both ears.
NOSE: Color consistent with the rest
of the face, smooth and symmetric
without tenderness and discharges
noted. Able to sniff and blow through
each nostril. Nasal mucosa is dark
pink, moist and free of exudates.
Nasal septum at midline, intact and
free of ulcers or perforations. Clear
frontal and maxillary sinuses upon
transillumination and are non-tender
to palpation and percussion.
MOUTH:Lips are pinkish, rough and
dry without lesions or swelling.
Gums are pink, moist and firm with
tight margins to the teeth, no
lesions, redness and swelling noted.
Buccal mucosa is pinkish, smooth
and moist without lesions. Tongue is
moist, pinkish at midline without

lesions, nodules or fasciculations,


papillae present on dorsal surface.
Smooth, pink and hard palate with
firm transverse rugae. Uvula is
pinkish, moist, hang freely in midline
without redness or transudate.
Tonsils are pink, symmetric without
exudates and swelling. Gag reflex is
intact.
NECK: Symmetric with head
centered and without bulging
masses. Full range of motion,
smooth and contracted. Trachea is
in midline. Thyroid gland
arepositioned midline, smooth, firm
and non tender. Lymph nodes are
not palpable.
CHEST & LUNGS: Scapulae
symmetric & nonprotruding.
Anteroposterior is less than
transverse diameter. Sternum at
midline and straight. Ribs slope
downward with symmetric
intercostals spaces. Depth, rhythm &
quality of respiration isshallow with
regular pace, relaxed, effortless and
quiet use of accessory
muscle.Respirations areirregular RR
= 36 cpm (Normal value = 2 years to
10 years: 20-28 cycles per minute).
No retractions and bulging noted.
Bronchial breath sounds were heard
over the trachea, bronchovesicular
breath sound over the primary
bronchi and vesicular breath sound
over the lung fields. No adventitious
sounds noted. Fremitus is symmetric

and easily identified in the upper


regions of the lungs. Chest
expansion was 5cm. Percussion
tone is resonance all over the lung
fields.Crackles were heard on the
right lung.Egophony soft and muffled
with distinguishable letter E.
Bronchophony is soft, muffled and
indistinct. Whispered pectoriloquy is
distant and very muffled.
HEART & PERIPHERAL
VASCULATURE: Apical pulse at
fifth intercostals space, left
midclavicular line with a rate of
105bpm. Rhythm and pace is
regular.S1 sound is distinct and
heard best at the apex (mitral valve).
S2 sound is distinct and heard best
on the base (pulmonic & aortic
valve). No extra heart sounds,
murmurs and varicosities
noted.Presence of pitting edema on
both feet with a grade of +1.
CAPILLARY REFILL TIME: pink
tone returns immediately to
blanched nail beds when pressure is
released.
Upper extremities (R)
pinkish; <1 sec
Upper extremities (L)
pinkish; <1 sec
Lower extremities (R)
pinkish; <1 sec
Lower extremities (L)
pinkish; <2 secs

PERIPHERAL PULSES:
(R)
Pulse
Temporal
Amplitude
101
Scale
+2
0 = Absent
Carotid
+1 = Weak
103
+2 = Normal
+2
+3 = Increased
Brachial
+4 = Bounding
104
+2
Radial
101
+3
Popliteal
101
+2
Posterior
tibialis 101
+2
Dorsalispedis
103
+2
ABDOMEN: Rounded and
symmetric without bulges. Striae not
noted. Umbilicus is at midline,
depressed and without bulging. Soft
gurgles and clicks heard all
throughout the quadrants of the
abdomen. Percussion tone is
tympany. Girth is 92 cm. No fluid
wave is transmitted. The borders
between tympany and dullness
remain relatively constant
throughout position changes.

Bowel sounds: (clicks/minute)


(R)
(L)
06

34

12

24

RECTUM & GENITALIA:


Assessment not conducted
BACK & EXTREMITIES: Uneven
weight bearing is evident. Widebased gait is noted. Client cannot
completely stand on his own
because client claims his body,
especially his feet, is still weak.
Posture is erect without exaggerated
curvature of cervical, thoracic and
lumbar spine. Spine is straight.
Client was able to perform full ROM
on his both lower extremities and on
his left upper extremity but with sligh
but with slight difficulty.Upper and
lower extremities are symmetric.

Muscle
strength:
(R)
(L)
5/5 4/5

4/5
4/5

Scale:
5 Full
ROM
against
gravity,
full
resistanc
e
4 Full
ROM
against
gravity,
some
resistanc
e
3 Full
ROM
with
gravity
2 Full
ROM
with
gravity
eliminate
d
(passive
motion)
1 Slight
Reaction
0 No
Reaction

NEUROLOGIC ASSESSMENT
Mental Status/ Cerebral Function:
Client is awake, responsive, alert,
and cooperative, appears to be
relaxed, and maintains eye contact.
Client states nickname Marky

when asked, states Lawaan


Elementary School when asked for
the name of his school and states
Grade 3 when asked for his grade
leve. Client listens and can follow
directions.
In the Glasgow Coma Scale, client
scores 15 observed by as follows:
eye
opening
response
is
spontaneous (rated 4); oriented
verbal response (rated 5); obeys
verbal commands (rated 6).
GCS scoring:
Eye response:
1 - no eye opening
2 - eye opening in response to pain
stimulus
3 - eye opening to speech
4 - spontaneous eye opening
Verbal Response:
1 - no verbal response
2 - incomprehensible sounds
3 - inappropriate words
4 - confused
5 oriented
Motor response:
1 - no motor response
2 - extension to pain
3 - abnormal flexion to pain
4 - flexion/withdrawal to pain
5 - localizes to pain
6 - obeys commands
Motor/Cerebellar Functions
Client can perform rapid-alternating
movements. Client was able to
perform finger-thumb test on the

right and left hand. Client can touch


his nose with his right and left hand.
Client needs assistance in standing
or ambulating.
Sensory Function
Client can differentiate between dull
and sharp objects on both arms as
well as the cheeks.
Cranial Nerve Testing
CN 1 (Olfactory): Correctly
identifies scent of banana peel
CN 2 (Optic): reads writings on the
notebbok at approximately 12-14
inches on both eyes
CN 3, 4 &6 (Oculomotor,
Trochlear, Abducens): full
extraoccular movements, (+)
PERRLA
CN 5 (Trigeminal): Corneal reflex
present; clenches teeth
CN 7 (Facial): Able to smile, frown,
wrinkle forehead, show teeth, puff
out cheeks, purses lips, raise
eyebrows &close eyes against
resistance.
CN 8 (Vestibulocochlear):
Whispered words heard within 2ft
both ears.
CN 9 & 10 (Glossopharyngeal
&Vagus): Uvula & palate rise
symmetrically when client says ah;
gag reflex present; swallows without
difficulty.
CN 11 (Spinal Accessory): Equal
shoulder shrug against resistance;
turns head in both directions against
resistance.

CN 12 (Hypoglossal): Protrudes
tongue in midline, able to push
tongue depressor in left & right side
of the mouth without difficulty
DEEP TENDON REFLEXES:
Biceps
Grading Deep
Tendon
(R) +2 Reflexes
+4

hyperactive,
(L) +2
very
brisk,
Triceps
rhythmic
oscillations
(R) +2 (clonus);
abnormal and
(L) +2
indicative
of
Brachioradialis disorder
(R) +2
+3 more
(L) not
brisk or active
assessed due
than normal,
to ISA
but
not
attached
indicative
of
disorder
Patellar
+2 normal,
(R) +2
usual
(L) +2
response
+1

Achilles
decreased,
(R) +2
less
active
(L) +2
than normal
0
no
response
Day 2: September 17, 2015
(2:30pm)
GENERAL APPEARANCE: Seen
patient on the bed awake, alert,

responsive, and coherent with ISA


on his left arm, with the following
vital signs:
BP=130/70mmHg
PR=104bpm
RR=40cpm
Temperature=37.4C/axilla
SKIN: Dark brown, evenly colored
skin tone. Skin is dry and warm. Skin
is thin with calluses noted on plantar
surface of both feet. Skin pinches
easily and immediately return to its
original position. Hematomas 15 mm
in diameter are seen on both upper
and lower extremities due to
previous IV injection site. With ISA
on his left hand..
CHEST & LUNGS: CHEST &
LUNGS: Scapulae symmetric &
nonprotruding. Anteroposterior is
less than transverse diameter.
Sternum at midline and straight.
Ribs slope downward with
symmetric intercostals spaces.
Depth, rhythm & quality of
respiration isshallow with regular
pace, relaxed, effortless and quiet
use of accessory
muscle.Respirations areirregular RR
= 36 cpm (Normal value = 2 years to
10 years: 20-28 cycles per minute).
No retractions and bulging noted.
Bronchial breath sounds were heard
over the trachea, bronchovesicular
breath sound over the primary
bronchi and vesicular breath sound

over the lung fields. No adventitious


sounds noted. Fremitus is symmetric
and easily identified in the upper
regions of the lungs. Chest
expansion was 5cm. Percussion
tone is resonance all over the lung
fields.Crackles were heard on the
right lung.Egophony soft and muffled
with distinguishable letter E.
Bronchophony is soft, muffled and
indistinct. Whispered pectoriloquy is
distant and very muffled.
HEART & PERIPHERAL
VASCULATURE: Apical pulse at
fifth intercostals space, left
midclavicular line with a rate of
105bpm. Rhythm and pace is
regular.S1 sound is distinct and
heard best at the apex (mitral valve).
S2 sound is distinct and heard best
on the base (pulmonic & aortic
valve). No extra heart sounds,
murmurs and varicosities
noted.Presence of pitting edema on
both feet with a grade of +1.
ABDOMEN: Rounded and
symmetric without bulges. Striae not
noted. Umbilicus is at midline,
depressed and without bulging. Soft
gurgles and clicks heard all
throughout the quadrants of the
abdomen. Percussion tone is
tympany. Girth is 84 cm.
No fluid wave is transmitted. The
borders between tympany and
dullness remain relatively constant
throughout position changes.

BACK & EXTREMITIES: Widebased gait is noted. Client can


already completely stand on his
own.Posture is erect without
exaggerated curvature of cervical,
thoracic and lumbar spine. Spine is
straight. Client was able to perform
full ROM on his both lower
extremities and upper
extremities.Upper and lower
extremities are symmetric.
Muscle
Scale:
strength:
5 Full ROM
(R)
(L)
against
5/5 5/5
gravity,
full
resistance
4 Full ROM
against
5/5
gravity, some
5/5
resistance
3 Full ROM
with gravity
2 Full ROM
with gravity
eliminated
(passive
motion)
1 Slight
Reaction
0

No
Reaction