PHYSICAL AND NEUROLOGICAL EXAMINATION

Day and Date: Wednesday, September 21, 2016

Time: 11:30 AM
Vital Signs
Temperature :
38.4C
PR
:
74 bpm
RR
:
regulated via mechanical ventilator at 18 cpm
BP
:
80/40 mmHg
O2 Sat
:
97%
General Survey
Current weight unidentified, (+) fever, (+) chills, GCS 6 (E1V1M4).

Physical Assessment
Assessment

Normal Findings

Actual Findings

Interpretation

Skin is uniform in
color, warm to
touch with good
skin turgor. No
cyanosis.

Skin is fair, warm

to touch and
uniform in color
but slightly darker
in the exposed
areas. Decreased
skin turgor noted.
(+) anasarca

Decreased skin
turgor and
anasarca indicates
dehydration.
Exposed areas are
usually darker
because of
exposure to the
heat of the sun.

Mucous
membranes pink
in color, moist with
no lesions or
inflammations.

Mucous
membranes pink
and moist with no
sores, lesions and
inflammations.

Hair is evenly
distributed. Scalp
is intact and free
of lesions and
pediculosis.

Hair is unevenly
distributed, thin
strand brunette in
color. White hair
noted upon
inspection. Fine
body hair noted

Integumentary
System
Methods of
Assessment Used:
Inspection
Palpation

Skin

Hair and Scalp

Within normal
range

Uneven
distribution of hair
indicates
deterioration given
the age.

Nails

Nails vary from

light skinned to
light brown in
darker skinned
individuals. Nails
are convex in
shape and firm
without clubbing.

over the body. No

scalp lesions,
dandruff, lice
noted.
Nails vary from
light skinned to
light brown in
darker skinned
individuals. Nails
are convex in
shape and firm
without clubbing.

Within normal
range

HEENT
Methods of
Assessment Used:
Inspection
Palpation

Head

Round and
symmetrical. No
palpable masses,
swelling and
lesions. Facial
features and
movements
symmetrical.

Round and
symmetrical. No
palpable masses,
swelling and
lesions. Facial
features and
movements
symmetrical.

Within normal
range

Eyes

In parallel
alignment with
smooth and white
sclera. Positive
pupillary reaction
to light and
blinking reflex.
Smooth, conjugate
movement of eyes
in all directions
without eyelid lag
and nystagmus.

Sclera is white
with no lesions.
Both eyes are
clear and bright in
parallel alignment.
Parallel
movements in all
directions noted.
Positive blinking
reflex noted.
Cornea is shiny
and smooth.
Pinpointed pupils
are noted at 2 mm
in size. Iris is
brown in color

Pinpointed pupils
indicates
disruption of
pontine
sympathetic
fibers.

Eyebrows and
eyelashes are
evenly distributed
with no lesions or
swelling. Eyelids
intact.

Ears

Neck

Pinkish peach
color conjunctiva
with no lesion
Consistent with
skin color and
aligned with the
external canthus
of the eyes. No
lesions,
tenderness and
swelling. No
palpable nodules
or exudates.
Skin is intact. No
palpable masses
or bulges, lymph
nodes and
swelling. Thyroid
glands not
enlarge.

Throat/Mouth

upon inspection.
No corrective
lenses or
eyeglasses noted.
Within normal
range
Fair distribution of
eyebrows and
eyelashes without
presence of
discharges,
swelling or
inflammations.
Eyelashes curves
outward without
crusting or
infestations.
Eyelids intact
without lesions.
Pinkish peach
color conjunctiva
with no lesions.
Aligned with the
external canthus
of the eyes.
Consistent with
skin color. No
lesions, nodules
and swelling
noted. Cerumen
noted upon
inspection and in
small amount.
Is in the midline
and movable 180
degrees without
feeling of
discomfort
reported. Left and
right superficial
cervical nodes not
palpable. No
bulges or masses,
lesions and
swelling noted.
Thyroid is in mid
lower half of the

Within normal
range

Within normal
range

Within normal
range

Within normal

Mucosa pink, no
redness or
inflammations and
lesions.

anterior neck. No
Enlargement,
tenderness and
nodularity noted.

Lips pink, moist

and intact.

Pink, moist,
smooth, glistening
and intact
mucosa. Tongue is
pink in color,
mobile with no
lesions or swelling
and any
discolorations.
Lateral margins
present. Tonsils
are pink and
indicate no signs
of inflammation.

Gums pink with no

lesions, swelling,
redness and
bleeding. No
discharges or
exudates.
Hard and soft
palate pink and
intact, teeth are
white in color, not
loose with good
occlusion and in
good repair.
Swallowing is
easily done
without difficulty
or feeling of pain.

Pulmonary System
Methods of
Assessment Used:

range

Within normal
range

Within normal
range

Moist, pink lips

noted without any
lesions and
swelling. No
cracks noted.
Gums are
consistent in color
with other mucosa
with no bleeding.
No lesions,
swelling and
exudates noted.
Teeth are white in
color. Hard and
soft palate is pink
and intact.
Dentures noted on
the upper portion
of the buccal
mucosa. Reports
no difficulty in
swallowing.

Within normal
range

 Inspection
Palpation
Auscultation

Respiratory rate
ranges from 18
-25 cycles per
minute. Equal rise
and fall of the
chest when
breathing, full and
even. Chest is
consistent with
skin color. Trachea
is in the midline.
Tactile fremitus
equal bilaterally.
Nose is
symmetrical with
no discharges.
Septum intact and
in midline.

Respiration
regulated at 18
cpm on
mechanical
ventilator, AC
mode, 40% FiO2,
TV: 500. Nose is
symmetrical with
no discharges and
nasal flaring.
Septum intact and
in midline.
Trachea is in the
midline. With ET
attached. There is
equal rise and fall
of the chest with
regular rate and
rhythm of
respiration without
any masses noted
upon palpation. No
pain reported over
the chest.
Breathing pattern
is even, no
dyspnea noted.
Vocal fremitus is
symmetric, equal
bilaterally on the
upper anterior
chest. There are
secretions but no
presence of cough.

Presence of
respiratory
distress. If there is
an increase in
fremitus this
indicates
accumulation of
fluid or exudates
in the lungs. Even
breathing
indicates no
difficulty in
respiration.

Heart rate of 60100 beats per

minute, regular.
Capillary refill of
less than 2
seconds. Blood
pressure of
90/60mmHg140/90mmHg

Pulse rate was

recorded as 74
bpm and is in
regular rhythm.
Blood pressure
was recorded as
80/40 mmHg. No
murmurs noted.
No chest pain
reported. Good

During mechanical
ventilation, a
breath for which
both the timing
and the size are
controlled by the
patient (i.e., the
breath is both
initiated
[triggered] and

Cardiovascular
System
Methods of
Assessment Used:
Inspection
Palpation
Auscultation

capillary refill less

than 2 seconds.
With spontaneous
breathing.

terminated
[cycled] by the
patient). Low
blood pressure
indicates
hypotension.

Abdomen is intact
with no lesions,
masses and
consistent with
skin color.
Umbilicus inverted
and in midline.
Audible bowel
sounds present 530 clicks per
minute.

No lesions, masses
and scars noted
over the abdomen.
Umbilicus noted,
inverted and in
midline. Bowel
sound audible at
four abdominal
quadrants with 12
clicks per minute
upon auscultation.
Last bowel
movement:
September 18,
2015, 5:30 in the
afternoon with soft
yellowish stool as
reported.

Within normal
range

No burning
sensation during
urination. Urine
output is 8001,200 ml/day if
intake is around 2
L/day

With intrajugular
insertion. Hooked
with PNSS 1 L on
KVO. Last voided:
September 20,
2016, in the
afternoon with
yellowish colored
urine with total
output of 350 cc
throughout the
shift.

Low urine output

indicates
dehydration

Gastrointestinal
System
Methods of
Assessment Used:
Inspection
Palpation
Percussion
Auscultation

Genitourinary
System
Methods of
Assessment Used:
Inspection

Musculoskeletal
System
Methods of
Assessment Used:
Inspection
Palpation

Posture erect,
head midline and
weight evenly
distributed. Both
feet point straight
ahead. All
movements
coordinated and
arms swings in
opposition.
Balance intact.

Immobilization on
all of the
extremities.
Decerebrate
posture.

Alteration of
arousal are a
spectrum of
abnormalities that
range from being
alert to
unresponsive
(comatose).
Decerebrate
posture indicates
upper pontine
damage.

Actual Findings

Interpretation

Neurological Examination
Category

Normal Findings

Mental Status
(as per Glasgow
Coma Scale)
Alert

Comatose

Oriented to person,
time and place.

Unresponsive

Coherent

Unresponsive

Able to remember

Unresponsive

Level of
Consciousness

Comatose is a
state of
unarousable
unresponsiveness
same as comatose

Orientation
same as comatose
Language test

same as comatose
Recall
Cranial Nerves
CN I
Olfactory

CN II
Optic

Able to smell and

recognize stimuli

unassessed

Normal

20x20 vision, able

to read, 3-5 mm
[pupil size]

Pupil size is 3 mm,

the rest are
unassessed

Indicates pontine
hemorrhage.

CN III, IV, VI
Oculomotor
Trochlear
Abducens

(+) Extraoccular
Movement (EOM);
Lateral Upward and
downward; pupils
reactive to light.

CN V
Trigeminal

Able to feel and

clearly identify
stimulus, with
bilateral facial
sensation. With
active corneal
reflex.

CN VII
Facial

(+) Corneal reflex ,

Facial symmetry
CN VIII
Vestibulocochlear

CN IX, X
Glossopharyngeal
Vagus

Able to hear
clearly, can
maintain balance

Pupil are
pinpointed,
reactive to light,
the rest are
unassessed

Indicates pontine
hemorrhage.

Indicates pontine
lesion
(-) unilateral
contraction, (-)
corneal reflex

Facial asymmetry,
rest are
unassessed

Facial asymmetry
indicates pontine
lesion

Comatose,
unassessed
unassessed

CN XI
Accessory (Spinal)

(+) gag reflex,

uvula at the
center, soft palate
rises

Absence of
movement, (-)
resistance

Comatose,
unassessed

CN XII
Hypoglossal

Able to shrug
shoulders against
resistance and able
to turn the head
side and against
resistance.
Able to move
tongue from side to
side

unassessed

Comatose,
unassessed

(+1) No visible or
palpable

No muscle
contraction is seen

Muscle Strength
Left Arm

(-) gag reflex, rest

are unassessed

Comatose,
unassessed

MMT Grading
System:
(+5) Full ROM

against gravity,
maximum
resistance
Right Arm
(+5) Full ROM
against gravity,
maximum
resistance
Left Leg

Right Leg

(+5) Full ROM

against gravity,
maximum
resistance
(+5) Full ROM
against gravity,
maximum
resistance

contraction

(+1) No visible or
palpable
contraction

(+1) No visible or
palpable
contraction

(+1) No visible or
palpable
contraction

or identified with
palpation; paralysis
No muscle
contraction is seen
or identified with
palpation; paralysis
No muscle
contraction is seen
or identified with
palpation; paralysis
No muscle
contraction is seen
or identified with
palpation; paralysis

Day and Date: Thursday, September 22, 2016

Time: 11:30 AM
Vital Signs
Temperature :
36.6C
PR
:
78 bpm
RR
:
regulated via mechanical ventilator at 18 cpm
BP
:
120/80 mmHg
O2 Sat
:
97%
General Survey
Current weight unidentified, (-) fever, (-) chills, GCS 5 (E1V1M3).

Physical Assessment
Assessment
Integumentary
System
Methods of
Assessment Used:
Inspection
Palpation

Normal Findings

Actual Findings

Interpretation

Skin

Hair and Scalp

Skin is uniform in
color, warm to
touch with good
skin turgor. No
cyanosis.

Skin is fair, warm

to touch and
uniform in color
but slightly darker
in the exposed
areas. Decreased
skin turgor noted.
(+) anasarca

Mucous
membranes pink
in color, moist with
no lesions or
inflammations.

Mucous
membranes pink
and moist with no
sores, lesions and
inflammations.

Hair is evenly
distributed. Scalp
is intact and free
of lesions and
pediculosis.

Hair is unevenly
distributed, thin
strand brunette in
color. White hair
noted upon
inspection. Fine
body hair noted
over the body. No
scalp lesions,
dandruff, lice
noted.

Nails
Nails vary from
light skinned to
light brown in
darker skinned
individuals. Nails
are convex in
shape and firm
without clubbing.

Nails vary from

light skinned to
light brown in
darker skinned
individuals. Nails
are convex in
shape and firm
without clubbing.

Decreased skin
turgor and
anasarca indicate
dehydration.
Exposed areas are
usually darker
because of
exposure to the
heat of the sun.
Within normal
range

Uneven
distribution of hair
indicates
deterioration given
the age.

Within normal
range

HEENT
Methods of
Assessment Used:
Inspection
Palpation

Head

Round and
symmetrical. No
palpable masses,

Round and
symmetrical. No
palpable masses,

Within normal
range

Eyes

swelling and
lesions. Facial
features and
movements
symmetrical.

swelling and
lesions. Facial
features and
movements
symmetrical.

In parallel
alignment with
smooth and white
sclera. Positive
pupillary reaction
to light and
blinking reflex.
Smooth, conjugate
movement of eyes
in all directions
without eyelid lag
and nystagmus.

Sclera is white
with no lesions.
Both eyes are
clear and bright in
parallel alignment.
Parallel
movements in all
directions noted.
Positive blinking
reflex noted.
Cornea is shiny
and smooth.
Pinpointed pupils
are noted at 2 mm
in size. Iris is
brown in color
upon inspection.
No corrective
lenses or
eyeglasses noted.

Eyebrows and
eyelashes are
evenly distributed
with no lesions or
swelling. Eyelids
intact.

Ears

Neck

Pinkish peach
color conjunctiva
with no lesion
Consistent with
skin color and
aligned with the
external canthus
of the eyes. No
lesions,
tenderness and
swelling. No

Fair distribution of
eyebrows and
eyelashes without
presence of
discharges,
swelling or
inflammations.
Eyelashes curves
outward without
crusting or
infestations.
Eyelids intact
without lesions.
Pinkish peach
color conjunctiva
with no lesions.
Aligned with the
external canthus
of the eyes.
Consistent with

Pinpointed pupils
indicates
disruption of
pontine
sympathetic
fibers.

Within normal
range

Within normal
range

Within normal
range

palpable nodules
or exudates.
Skin is intact. No
palpable masses
or bulges, lymph
nodes and
swelling. Thyroid
glands not
enlarge.

Throat/Mouth

Mucosa pink, no
redness or
inflammations and
lesions.

Lips pink, moist

and intact.

Gums pink with no

lesions, swelling,
redness and
bleeding. No
discharges or
exudates.
Hard and soft
palate pink and
intact, teeth are
white in color, not

skin color. No
lesions, nodules
and swelling
noted. Cerumen
noted upon
inspection and in
small amount.
Is in the midline
and movable 180
degrees without
feeling of
discomfort
reported. Left and
right superficial
cervical nodes not
palpable. No
bulges or masses,
lesions and
swelling noted.
Thyroid is in mid
lower half of the
anterior neck. No
Enlargement,
tenderness and
nodularity noted.
Pink, moist,
smooth, glistening
and intact
mucosa. Tongue is
pink in color,
mobile with no
lesions or swelling
and any
discolorations.
Lateral margins
present. Tonsils
are pink and
indicate no signs
of inflammation.

Within normal
range

Within normal
range

Within normal
range

Within normal
range

Moist, pink lips

noted without any
lesions and
swelling. No
cracks noted.
Gums are
consistent in color

Within normal
range

loose with good

occlusion and in
good repair.
Swallowing is
easily done
without difficulty
or feeling of pain.

with other mucosa

with no bleeding.
No lesions,
swelling and
exudates noted.

Respiratory rate
ranges from 18
-25 cycles per
minute. Equal rise
and fall of the
chest when
breathing, full and
even. Chest is
consistent with
skin color. Trachea
is in the midline.
Tactile fremitus
equal bilaterally.
Nose is
symmetrical with
no discharges.
Septum intact and
in midline.

Respiration
regulated at 18
cpm on
mechanical
ventilator, AC
mode, 40% FiO2,
TV: 500. Nose is
symmetrical with
no discharges and
nasal flaring.
Septum intact and
in midline.
Trachea is in the
midline. With ET
attached. There is
equal rise and fall
of the chest with
regular rate and
rhythm of
respiration without
any masses noted
upon palpation. No
pain reported over
the chest.
Breathing pattern
is even, no
dyspnea noted.
Vocal fremitus is

Teeth are white in

color. Hard and
soft palate is pink
and intact.
Dentures noted on
the upper portion
of the buccal
mucosa. Reports
no difficulty in
swallowing.

Pulmonary System
Methods of
Assessment Used:
Inspection
Palpation
Auscultation

Presence of
respiratory
distress. If there is
an increase in
fremitus this
indicates
accumulation of
fluid or exudates
in the lungs. Even
breathing
indicates no
difficulty in
respiration.

symmetric, equal
bilaterally on the
upper anterior
chest. There are
secretions but no
presence of cough.
Cardiovascular
System
Methods of
Assessment Used:
Inspection
Palpation
Auscultation

Heart rate of 60100 beats per

minute, regular.
Capillary refill of
less than 2
seconds. Blood
pressure of
90/60mmHg140/90mmHg

Pulse rate was

recorded as 78
bpm and is in
regular rhythm.
Blood pressure
was recorded as
120/80 mmHg. No
murmurs noted.
Good capillary
refill less than 2
seconds. (+)
spontaneous
breathing.

During mechanical
ventilation, a
breath for which
both the timing
and the size are
controlled by the
patient (i.e., the
breath is both
initiated
[triggered] and
terminated
[cycled] by the
patient).

Abdomen is intact
with no lesions,
masses and
consistent with
skin color.
Umbilicus inverted
and in midline.
Audible bowel
sounds present 530 clicks per
minute.

No lesions, masses
and scars noted
over the abdomen.
Umbilicus noted,
inverted and in
midline. Bowel
sound audible at
four abdominal
quadrants with 14
clicks per minute
upon auscultation.
Last bowel
movement:
September 18,
2015, 5:30 in the
afternoon with soft
yellowish stool as
reported.

Within normal
range

Gastrointestinal
System
Methods of
Assessment Used:
Inspection
Palpation
Percussion
Auscultation

Genitourinary
System
Methods of
Assessment Used:
Inspection

No burning
sensation during
urination. Urine
output is 8001,200 ml/day if
intake is around 2
L/day

With intrajugular
insertion. Last
voided: September
22, 2016, 10:30 in
the evening with
dark yellow
colored urine with
total output of 800
cc throughout the
shift.

Within normal
range

Posture erect,
head midline and
weight evenly
distributed. Both
feet point straight
ahead. All
movements
coordinated and
arms swings in
opposition.
Balance intact.

Immobilization on
all of the
extremities.
Decerebrate
posture.

Alteration of
arousal are a
spectrum of
abnormalities that
range from being
alert to
unresponsive
(comatose).
Decerebrate
posture indicates
upper pontine
damage.

Actual Findings

Interpretation

Musculoskeletal
System
Methods of
Assessment Used:
Inspection
Palpation

Neurological Examination
Category

Normal Findings

Mental Status
(as per Glasgow
Coma Scale)
Alert

Comatose

Oriented to person,
time and place.

Unresponsive

Level of
Consciousness

Comatose is a
state of
unarousable
unresponsiveness
same as comatose

Orientation
Coherent

Unresponsive

Able to remember

Unresponsive

same as comatose
Language test

same as comatose
Recall
Cranial Nerves
CN I
Olfactory

Able to smell and

recognize stimuli

unassessed

Normal

CN II
Optic

20x20 vision, able

to read, 3-5 mm
[pupil size]

Pupil size is 2 mm,

the rest are
unassessed

Indicates pontine
hemorrhage.

CN III, IV, VI
Oculomotor
Trochlear
Abducens

(+) Extraoccular
Movement (EOM);
Lateral Upward and
downward; pupils
reactive to light.

CN V
Trigeminal

Able to feel and

clearly identify
stimulus, with
bilateral facial
sensation. With
active corneal
reflex.

CN VII
Facial

CN VIII
Vestibulocochlear

CN IX, X
Glossopharyngeal
Vagus
CN XI
Accessory (Spinal)

(+) Corneal reflex ,

Facial symmetry

Able to hear
clearly, can
maintain balance

(+) gag reflex,

uvula at the
center, soft palate
rises

Pupil are
pinpointed,
reactive to light,
the rest are
unassessed

Indicates pontine
hemorrhage.

Indicates pontine
lesion
(-) unilateral
contraction, (-)
corneal reflex

Facial asymmetry,
rest are
unassessed

Facial asymmetry
indicates pontine
lesion

Comatose,
unassessed
unassessed

(-) gag reflex, rest

are unassessed

Comatose,
unassessed

CN XII
Hypoglossal

Muscle Strength
Left Arm

Right Arm

Able to shrug
shoulders against
resistance and able
to turn the head
side and against
resistance.

Absence of
movement, (-)
resistance

Comatose,
unassessed

Able to move
tongue from side to
side

unassessed

Comatose,
unassessed

(+1) No visible or
palpable
contraction

No muscle
contraction is seen
or identified with
palpation; paralysis

MMT Grading
System:
(+5) Full ROM
against gravity,
maximum
resistance
(+5) Full ROM
against gravity,
maximum
resistance

Left Leg
(+5) Full ROM
against gravity,
maximum
resistance
Right Leg
(+5) Full ROM
against gravity,
maximum
resistance

(+1) No visible or
palpable
contraction

(+1) No visible or
palpable
contraction

(+1) No visible or
palpable
contraction

No muscle
contraction is seen
or identified with
palpation; paralysis
No muscle
contraction is seen
or identified with
palpation; paralysis
No muscle
contraction is seen
or identified with
palpation; paralysis

Day and Date: Friday, September 23, 2016

Time: 11:30 AM
Vital

Signs
Temperature :
PR
:
RR
:
BP
:

36.4C
81 bpm
regulated via mechanical ventilator at 18 cpm
110/90 mmHg

 O2 Sat
:
97%
General Survey
Current weight unidentified, (-) fever, (-) chills, GCS 5 (E1V1M3).

Physical Assessment
Assessment

Normal Findings

Actual Findings

Interpretation

Skin is uniform in
color, warm to
touch with good
skin turgor. No
cyanosis.

Skin is fair, warm

to touch and
uniform in color
but slightly darker
in the exposed
areas. Decreased
skin turgor noted.
(+) anasarca

Decreased skin
turgor and
anasarca indicate
dehydration.
Exposed areas are
usually darker
because of
exposure to the
heat of the sun.

Mucous
membranes pink
in color, moist with
no lesions or
inflammations.

Mucous
membranes pink
and moist with no
sores, lesions and
inflammations.

Hair is evenly
distributed. Scalp
is intact and free
of lesions and
pediculosis.

Hair is unevenly
distributed, thin
strand brunette in
color. White hair
noted upon
inspection. Fine
body hair noted
over the body. No
scalp lesions,
dandruff, lice
noted.

Integumentary
System
Methods of
Assessment Used:
Inspection
Palpation

Skin

Hair and Scalp

Nails
Nails vary from
light skinned to
light brown in
darker skinned
individuals. Nails
are convex in
shape and firm

Nails vary from

light skinned to
light brown in
darker skinned
individuals. Nails

Within normal
range

Uneven
distribution of hair
indicates
deterioration given
the age.

Within normal
range

without clubbing.

are convex in
shape and firm
without clubbing.

HEENT
Methods of
Assessment Used:
Inspection
Palpation

Head

Round and
symmetrical. No
palpable masses,
swelling and
lesions. Facial
features and
movements
symmetrical.

Round and
symmetrical. No
palpable masses,
swelling and
lesions. Facial
features and
movements
symmetrical.

Within normal
range

Eyes

In parallel
alignment with
smooth and white
sclera. Positive
pupillary reaction
to light and
blinking reflex.
Smooth, conjugate
movement of eyes
in all directions
without eyelid lag
and nystagmus.

Sclera is white
with no lesions.
Both eyes are
clear and bright in
parallel alignment.
Parallel
movements in all
directions noted.
Positive blinking
reflex noted.
Cornea is shiny
and smooth.
Pinpointed pupils
are noted at 2 mm
in size. Iris is
brown in color
upon inspection.
No corrective
lenses or
eyeglasses noted.

Pinpointed pupils
indicates
disruption of
pontine
sympathetic
fibers.

Eyebrows and
eyelashes are
evenly distributed
with no lesions or
swelling. Eyelids
intact.

Fair distribution of
eyebrows and
eyelashes without
presence of

Within normal
range

Ears

Neck

Pinkish peach
color conjunctiva
with no lesion
Consistent with
skin color and
aligned with the
external canthus
of the eyes. No
lesions,
tenderness and
swelling. No
palpable nodules
or exudates.
Skin is intact. No
palpable masses
or bulges, lymph
nodes and
swelling. Thyroid
glands not
enlarge.

Throat/Mouth

Mucosa pink, no
redness or
inflammations and
lesions.

discharges,
swelling or
inflammations.
Eyelashes curves
outward without
crusting or
infestations.
Eyelids intact
without lesions.
Pinkish peach
color conjunctiva
with no lesions.
Aligned with the
external canthus
of the eyes.
Consistent with
skin color. No
lesions, nodules
and swelling
noted. Cerumen
noted upon
inspection and in
small amount.
Is in the midline
and movable 180
degrees without
feeling of
discomfort
reported. Left and
right superficial
cervical nodes not
palpable. No
bulges or masses,
lesions and
swelling noted.
Thyroid is in mid
lower half of the
anterior neck. No
Enlargement,
tenderness and
nodularity noted.
Pink, moist,
smooth, glistening
and intact
mucosa. Tongue is
pink in color,

Within normal
range

Within normal
range

Within normal
range

Within normal
range

Lips pink, moist

and intact.

Gums pink with no

lesions, swelling,
redness and
bleeding. No
discharges or
exudates.
Hard and soft
palate pink and
intact, teeth are
white in color, not
loose with good
occlusion and in
good repair.
Swallowing is
easily done
without difficulty
or feeling of pain.

mobile with no
lesions or swelling
and any
discolorations.
Lateral margins
present. Tonsils
are pink and
indicate no signs
of inflammation.

Within normal
range

Within normal
range

Moist, pink lips

noted without any
lesions and
swelling. No
cracks noted.
Gums are
consistent in color
with other mucosa
with no bleeding.
No lesions,
swelling and
exudates noted.

Within normal
range

Teeth are white in

color. Hard and
soft palate is pink
and intact.
Dentures noted on
the upper portion
of the buccal
mucosa. Reports
no difficulty in
swallowing.

Pulmonary System
Methods of
Assessment Used:
Inspection
Palpation
Auscultation

Respiratory rate
ranges from 18
-25 cycles per
minute. Equal rise
and fall of the
chest when
breathing, full and
even. Chest is
consistent with
skin color. Trachea

Respiration
regulated at 18
cpm on
mechanical
ventilator, AC
mode, 40% FiO2,
TV: 500. Nose is
symmetrical with
no discharges and
nasal flaring.

Presence of
respiratory
distress. If there is
an increase in
fremitus this
indicates
accumulation of
fluid or exudates
in the lungs. Even
breathing

is in the midline.
Tactile fremitus
equal bilaterally.
Nose is
symmetrical with
no discharges.
Septum intact and
in midline.

Septum intact and

in midline.
Trachea is in the
midline. With ET
attached. There is
equal rise and fall
of the chest with
regular rate and
rhythm of
respiration without
any masses noted
upon palpation. No
pain reported over
the chest.
Breathing pattern
is even, no
dyspnea noted.
Vocal fremitus is
symmetric, equal
bilaterally on the
upper anterior
chest. There are
secretions but no
presence of cough.

indicates no
difficulty in
respiration.

Heart rate of 60100 beats per

minute, regular.
Capillary refill of
less than 2
seconds. Blood
pressure of
90/60mmHg140/90mmHg

Pulse rate was

recorded as 78
bpm and is in
regular rhythm.
Blood pressure
was recorded as
120/80 mmHg. No
murmurs noted.
Good capillary
refill less than 2
seconds. (+)
spontaneous
breathing.

During mechanical
ventilation, a
breath for which
both the timing
and the size are
controlled by the
patient (i.e., the
breath is both
initiated
[triggered] and
terminated
[cycled] by the
patient).

Abdomen is intact

No lesions, masses

Within normal

Cardiovascular
System
Methods of
Assessment Used:
Inspection
Palpation
Auscultation

Gastrointestinal
System
Methods of
Assessment Used:

Inspection
Palpation
Percussion
Auscultation

with no lesions,
masses and
consistent with
skin color.
Umbilicus inverted
and in midline.
Audible bowel
sounds present 530 clicks per
minute.

and scars noted

over the abdomen.
Umbilicus noted,
inverted and in
midline. Bowel
sound audible at
four abdominal
quadrants with 15
clicks per minute
upon auscultation.
Last bowel
movement:
September 18,
2015, 5:30 in the
afternoon with soft
yellowish stool as
reported.

range

No burning
sensation during
urination. Urine
output is 8001,200 ml/day if
intake is around 2
L/day

With intrajugular
insertion. Last
voided: September
21, 2016, 10:30 in
the evening with
dark yellow
colored urine with
total output of 900
cc throughout the
shift.

Within normal
range

Posture erect,
head midline and
weight evenly
distributed. Both
feet point straight
ahead. All
movements
coordinated and
arms swings in
opposition.
Balance intact.

Immobilization on
all of the
extremities.
Decerebrate
posture.

Alteration of
arousal are a
spectrum of
abnormalities that
range from being
alert to
unresponsive
(comatose).
Decerebrate
posture indicates
upper pontine

Genitourinary
System
Methods of
Assessment Used:
Inspection

Musculoskeletal
System
Methods of
Assessment Used:
Inspection
Palpation

damage.

Neurological Examination
Category

Normal Findings

Actual Findings

Interpretation

Mental Status
(as per Glasgow
Coma Scale)
Alert

Comatose

Oriented to person,
time and place.

Unresponsive

Coherent

Unresponsive

Able to remember

Unresponsive

Level of
Consciousness

Comatose is a
state of
unarousable
unresponsiveness
same as comatose

Orientation
same as comatose
Language test

same as comatose
Recall
Cranial Nerves
CN I
Olfactory

Able to smell and

recognize stimuli

unassessed

Normal

CN II
Optic

20x20 vision, able

to read, 3-5 mm
[pupil size]

Pupil size is 2 mm,

the rest are
unassessed

Indicates pontine
hemorrhage.

CN III, IV, VI
Oculomotor
Trochlear
Abducens

(+) Extraoccular
Movement (EOM);
Lateral Upward and
downward; pupils
reactive to light.

CN V
Trigeminal

Able to feel and

clearly identify
stimulus, with
bilateral facial
sensation. With
active corneal

Pupil are
pinpointed,
reactive to light,
the rest are
unassessed

Indicates pontine
hemorrhage.

Indicates pontine
lesion
(-) unilateral
contraction, (-)
corneal reflex

CN VII
Facial

reflex.
(+) Corneal reflex ,
Facial symmetry

CN VIII
Vestibulocochlear

CN IX, X
Glossopharyngeal
Vagus

Able to hear
clearly, can
maintain balance

Facial asymmetry,
rest are
unassessed

Facial asymmetry
indicates pontine
lesion

Comatose,
unassessed
unassessed

CN XI
Accessory (Spinal)

(+) gag reflex,

uvula at the
center, soft palate
rises

Absence of
movement, (-)
resistance

Comatose,
unassessed

CN XII
Hypoglossal

Able to shrug
shoulders against
resistance and able
to turn the head
side and against
resistance.
Able to move
tongue from side to
side

unassessed

Comatose,
unassessed

(+1) No visible or
palpable
contraction

No muscle
contraction is seen
or identified with
palpation; paralysis

Muscle Strength
Left Arm

Right Arm

(-) gag reflex, rest

are unassessed

Comatose,
unassessed

MMT Grading
System:
(+5) Full ROM
against gravity,
maximum
resistance
(+5) Full ROM
against gravity,
maximum
resistance

Left Leg
(+5) Full ROM
against gravity,
maximum
resistance

(+1) No visible or
palpable
contraction

(+1) No visible or
palpable
contraction

No muscle
contraction is seen
or identified with
palpation; paralysis
No muscle
contraction is seen
or identified with
palpation; paralysis
No muscle
contraction is seen

Right Leg
(+5) Full ROM
against gravity,
maximum
resistance

(+1) No visible or
palpable
contraction

or identified with
palpation; paralysis