Abdomen

 Inspection: Scaphoid Abdomen. Erythema, dilated veins, rashes, and abdominal pulsations were
not noted. No inflammation and masses were seen. 
 Auscultation: Normo-active bowel sounds were heard. No bruit. Bowel clicks=13/min
 Percussion: Tympanitic gastric and splenic area.
 Palpation: no tenderness noted upon palpation. (-) Murphy’s sign.

Extremities
 Inspection: Upper and lower extremities were symmetrical. No varicose veins or nodule noted.
No swelling was seen on both right and left lower extremities.
 Palpation: Dry and warm to touch. No masses were noted. Capillary filling <2 seconds.

Neurologic Function
Mental Status: Patient was alert, relaxed and cooperative. Speech was fluent and words were clear.
Thought process was coherent and insight was good. Recent and remote memories were intact. There was
no evidence of disordered thinking.

Manual Muscle Testing (MMT):

Muscle Group Right Left

Shoulder flexors 5 5
Shoulder extensors 5 5
Shoulder abductors 5 5
Shoulder adductors 5 5
Elbow flexors 5 5
Elbow extensors 5 5
Pronators 5 5
Supinator 5 5
Wrist flexors 5 5
Wrist extensors 5 5
Plantar flexors 5 5
Dorsiflexors 5 5

Sensory Assessment: Patient had 100% intact sensation as to pain, light, touch and deep pressure on all
exposed body surfaces.

Deep Tendon Reflex:

Right Tendon Left

Normoreflexic Biceps brachii Normoreflexic
Normoreflexic Triceps brachii Normoreflexic
Normoreflexic Brachioradialis Normoreflexic
Normoreflexic Patellar Normoreflexic
Normoreflexic Achilles Normoreflexic
Superficial Reflex: Patient has (-) Babinski reflex on both feet.
Cranial Nerves:
Cranial Nerves Right
I. Olfactory Able to distinguish smell of coffee
with eyes closed and left nostril
covered
II. Optic Pupils round and reactive to light
accommodation with positive direct
and consensual light reflex
III. Oculomotor Able to open right eyelid
Able to look up and down, medially,
and upward inward.
(+) direct pupillary reflex
(+) consensual light reflex
IV. Trochlear Able to move eye downward and
inward
V. Trigeminal Able to sense object on surface of right
side of the face
Able to elevate and depress the jaw
with no deviation or asymmetry
(+) blink corneal reflex
(+) jaw jerk
VI. Abducens Able to look outward and laterally
VII. Facial Able to perform all facial expressions
with no deviation or asymmetry
(+) Blink Reflex on the right eye
VIII. Vestibulocochlear Can hear 3 out of 3 words on
whispered voice test with left ear
covered
IX. Glossopharyngeal Able to swallow
X. Vagus (+) Gag reflex
Left
Able to distinguish smell of coffee with
eyes closed and right nostril covered
Pupils round and reactive to light
accommodation with positive direct and
consensual light reflex
Able to open left eyelid
Able to look up and down, medially, and
upward inward.
(+) direct pupillary reflex
(+) consensual light reflex
Able to move eye downward and inward
Able to sense object on surface of left
side of the face
Able to elevate and depress the jaw with
no deviation or asymmetry
(+) blink corneal reflex
(+) jaw jerk
Able to look outward and laterally
Able to perform all facial expressions
with no deviation or asymmetry
(+) Blink Reflex on the left eye
Can hear 3 out of 3 words on whispered
voice test with right ear covered
Able to swallow
(+) Gag reflex
 XI. Spinal/Accessory Able to shrug shoulders with or
without resistance.
Able to perform right lateral neck
flexion with left rotation against
resistance
XII. Hypoglossal Can perform all tongue movements
with no deviation
Test for Meningitis:
(-) Brudzinski’s sign
(-) Kernig’s sign
Able to shrug shoulders with or without
resistance.
Able to perform left lateral neck flexion
with right rotation against resistance
Can perform all tongue movements with
no deviation