PHYSICAL EXAMINATION

General Survey: The patient is awake, conscious, ambulatory, afebrile, and not in cardiopulmonary
distress.

Head/Neck: No gross deformities; non-sunken eyeballs, anicteric sclerae, no eye discharges, pink
palpebral conjunctiva; No ear pain/ discharge; No naso-oral discharges, non-congested nasal turbinates;
No neck masses

Lymph nodes: no cervical lymphadenopathies

LUNGS: Symmetyrical chest wall expansion, equal tactile fremitus, resonant, clear breath sounds

HEART: Adynamic precordium, no heaves/thrills, normal heart rate with regular rhythm, no murmurs, no
extra heart sounds

Abdomen: Protuberant, Flabby, non-distended, no lesions, with normoactive bowel sounds, tympanitic,
non-tender, no masses palpated

Not assessed

Skin: No lesions, no pallor, no jaundice, no cyanosis; warm to touch, with good skin turgor
Full and Equal peripheral pulses; no edema; good muscle tone and bulk; no limitation in range of motion

Genitalia:
Male: Tanner Stage __; normal, triangular distribution of hair; no lesions, no gross deformities, no
discharges; non-tender
Female: Tanner Stage __; normal, inverted triangle distribution of hair; no lesions, no abnormal growth, no
discharges; non-tender

Glasgow Coma Scale 15 (E4 V5 M6)

A. Cerebral: Concious, coherent, oriented to three spheres of consciousness
C. Cranial Nerves:
I. Olfactory- able to smell
II. Optic- 2-3 mm , equally reactive to light and accommodation
III, IV, VI. Occulomotor, Trochlear, Abducens- intact EOMs
V. Trigeminal- intact facial sensation; able to clench jaw
VII. Facial- (-) facial assymetry
VIII. Vestibulocochlear - able to hear
IX/X. Glossopharyngeal, Vagus-(+) gag reflex
XI. SpinalAccessory Nerve- able to shrug shoulders and turn head side to side
XII. Hypoglossal- able to protrude tongue (-) tongue deviation, (-)slurring of speech

D. Sensory
D.1.Pain and Light Touch Sensation: intact
D.2 Facial sensation over the skin supplied by V1, V2, V3 on both the right and left side of the
face: intact; no asymmetry
D.3 Right Upper Extremity: 100%
Left Upper Extremity: 100%
 Right Lower Extremity: 100%
Left Lower Extremity: 100%

E. Motor:
E.1 Right Upper Extremity: 5/5
E.2 Left Upper Extremity: 5/5
E.3 Right Lower Extremity: 5/5
E.4 Left Lower Extremity: 5/5

F. Deep Tendon Reflexes

F.1 Right Biceps Reflex: +2
F.2 Left Biceps Reflex: +2
F.3 Right Patellar Reflex: +2
F.4 Left Patellar Reflex: +2

Cerebellar: (-) nystagmus, (-) tremors, normal gait

(-) Babinski (-) Kernigs sign

(-) Clonus (-) Nuchal Rigidity

Cranial Nerves: I. Olfactory- not assessed II. Optic- 2-3 mm , equally reactive to light and
accommodation III, IV, VI. Occulomotor, Trochlear, Abducens- intact EOMs V. Trigeminal- intact
facial sensation; able to clench jaw VII. Facial- (-) facial assymetry VIII. Vestibulocochlear - able to
hear IX/X. Glossopharyngeal, Vagus-(+) gag reflex XI. SpinalAccessory Nerve- able to shrug
shoulders and turn head side to side XII. Hypoglossal- able to protrude tongue (-) tongue deviation, (-
)slurring of speech Sensory D.1.Pain and Light Touch Sensation: intact D.2 Facial sensation over the
skin supplied by V1, V2, V3 on both the right and left side of the face: intact; no asymmetry D.3
Right Upper Extremity: 100% Left Upper Extremity: 100% Right Lower Extremity: 100% Left
Lower Extremity: 100% Motor: E.1 Right Upper Extremity: 5/5 E.2 Left Upper Extremity: 5/5 E.3
Right Lower Extremity: 5/5 E.4 Left Lower Extremity: 5/5 Deep Tendon Reflexes F.1 Right Biceps
Reflex: +2 F.2 Left Biceps Reflex: +2 F.3 Right Patellar Reflex: +2 F.4 Left Patellar Reflex: +2
Cerebellar: (-) nystagmus, (-) tremors, normal gait (-) Babinski (-) Kernigs sign (-) Clonus (-) Nuchal
Rigidity

Glasgow Coma Scale 15 (E4 V5 M6)

Cerebral: Concious, coherent, oriented to three spheres of consciousness

Cranial Nerves:

I. Olfactory- able to smell

II. Optic- 2-3 mm , equally reactive to light and accommodation

III, IV, VI. Occulomotor, Trochlear, Abducens- intact EOMs

V. Trigeminal- intact facial sensation; able to clench jaw

VII. Facial- (-) facial assymetry

VIII. Vestibulocochlear - able to hear

IX/X. Glossopharyngeal, Vagus-(+) gag reflex

 XI. SpinalAccessory Nerve- able to shrug shoulders and turn head side to side

XII. Hypoglossal- able to protrude tongue (-) tongue deviation, (-)slurring of speech

D. Sensory

D.1.Pain and Light Touch Sensation: intact

D.2 Facial sensation over the skin supplied by V1, V2, V3 on both the right and left side of the

face: intact; no asymmetry

D.3 Right Upper Extremity: 100%

Left Upper Extremity: 100%

Right Lower Extremity: 100%

Left Lower Extremity: 100%

E. Motor:

E.1 Right Upper Extremity: 5/5

E.2 Left Upper Extremity: 5/5

E.3 Right Lower Extremity: 5/5

E.4 Left Lower Extremity: 5/5

F. Deep Tendon Reflexes

F.1 Right Biceps Reflex: +2

F.2 Left Biceps Reflex: +2

F.3 Right Patellar Reflex: +2

F.4 Left Patellar Reflex: +2

Cerebellar: (-) nystagmus, (-) tremors, normal gait

(-) Babinski (-) Kernigs sign

(-) Clonus (-) Nuchal Rigidity