Physical Examination

VITAL SIGNS

Temperature : 36 ℃
Pulse Rate : 80 bpm
Respiratory Rate : 18 cpm
Blood Pressure : 120/70 mmHg

GENERAL: Client appears to be healthy in body build. He is wearing a white t-shirt and a short with green and
black accents. He appears to be wearing an id sling on his neck and always carrying a water tumbler with him. He
is calm and responsive.
SKIN: Client appears to be in brownish skin tone. Skin is dry and moist in appearance. No erythema or
discoloration noted. No signs of skin infection noted. No skin scaling and scarring noted.
EENT: Sclera is white in appearance. Pupils are equally round and reactive to light and accommodation. They are
constricted. Conjunctive is pinkish in appearance. No discharges, redness, and lacrimal tearing noted. No signs of
infection. Ears are symmetrically in shape. Non-tender when touch. Presence of cerumen noted. No foul
discharges and infection noted. Nares are symmetrically in shape. No foul smelling discharges and pain noted.
Tongue is pink and moist in appearance. No lesions noted. Teeth are aligning in place. Presence of dental caries
noted at least in 3-4 tooth. Gums are pinkish. No laceration or ulceration noted.
HEAD, SCALP, and HAIR: Head is atraumatic. Non tender when touch. Scalp is moist. No tearing/ scarring
noted. Hair is white to grayish in appearance. No infestation noted.
CARDIOVASCULAR: No crackles or wheezing noted when auscultated. No troubles in breathing noted.
GAIT and BALANCE: Client appears to be walking in normal pacing with arms swaying freely at each side.
Stand erect when walking. Maintains balance for at least 10 seconds. No crepitation noted.
PSYCH: Client is awake and responsive. His mood is calm and shows appropriate affect. He is cooperative. No
signs of aggression or mood changes noted. Easily distracted to low stimuli. He is oriented to time, place, and
person. No signs of hallucination or illusion noted.
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Neurological Examination

I. Mental Status Examination

- The client is oriented to time, place, and person

II. Level of Consciousness (Glasgow Coma Scale)

- Eye opening is interpreted spontaneous which is scored by 4
- Verbal response is interpreted oriented which is scored by 5
- Motor response is interpreted obeys command which is scored by 6

III. Sensory Nerve Assessment

A. Test for Primary Sensation:
- Able to identify area of light touch
- Able to identify the differences between sharp and dull sensations

B. Test for Cortical & Discriminatory Sensation:

- Able to identify two points: Forearm, Back, Fingertips (Two-point discrimination)
- Able to identify correct object (Stereognosis)
- Able to identify correct number (Graphesthesia)
- Able to identify the differences between hot and cold (Temperature testing)
- Able to identify correction direction (Kinesthesia)
IV. Motor Nerve Assessment
- Client is able to resist against resistance
- Client appears to be walking in normal pacing with arms swaying freely at each side
- No crepitation noted when walking or performing simple task (writing and holding an object)

V. Cerebellar Assessment
A. Finger-to-Nose Test
- Able to touch nose accurately
B. Ankle-to-Tibia Test
- Able to run each heel smoothly down each shin
C. Finger-to-Thumb Test
- Able to rapidly taps each finger to thumb
D. Romberg’s test
- Able to stand straight for 10 seconds with minimal swaying
E. Walk Naturally
- Steady gait with minimal arm swaying
F. Tandem Walk
- Able to maintains balance with tandem walk
G. Arms Straight test
- Able to hold arms steadily for 10 seconds

VI. Cranial Nerve Assessment

A. CN I – OLFACTORY NERVE
- Able to identify the correct scent
B. CN II – OPTIC NERVE
 Visual acuity – client is able to read letters or words from a distance
 Visual field – client is able to see an object in peripheral field
C. CN III (OCULOMOTOR NERVE), CN IV (TROCLEAR NERVE), CN VI (ABDUCENS
NERVE)
- Pupils equally round and reactive to light and accommodation.
D. CN V – TRIGEMINAL NERVE
- Able to clench, open, and close jaw
E. CN VII – FACIAL NERVE
- Able to perform different facial expressions such as smiling, frowning, and cheek blowing
F. CN VIII – ACOUSTIC NERVE
- Able to hear and repeat the whispered words
G. CN XI – SPINAL ACCESSORY NERVE
- Able to hold against resistance
H. CN XII – HYPOGLOSSAL NERVE
- Able to move tongue side by side smoothly