after geno gram and whole PE

8/7/2019 after geno gram and whole PE

1/17

C. HISTORY OF PAST ILLNESS

According to the information given by Mr. Jacob, he had chickenpox and measles

when he was young and had minor coughs, colds and fever. His first hospitalization

was on year 2006 and 2008. He was been diagnosed with the same diagnosis (CVA

infarct), Diabetes Mellitus type II and Hypertension and rushed to the same hospital.

He was ordered to have a maintenance medicine of metoprolol with irregular

intakes. He was also instructed to control his diet. According to the chart, even

though he had the same condition there were no residuals of it are left.

D. HISTORY OF PRESENT ILLNESS

On August 9, a day before the admission, the family went to a fiesta in one of

the town of Pampanga and ate too much including fatty foods such as Pork chop

and Sisig.

August 10 about 2 hours prior to the admission, Mr. Jacob experienced

sudden dizziness while he was watching television. He tried drinking his home

medication which is metoprolol but no improvement happened. He also felt

weakness of his left extremities that is why his eldest son suddenly rushed him to

the same hospital he was confined before.

Upon admission around 11:30 am, he was received awake conscious and

coherent with complains of slurring of speech with weakness at left extremities. The

client also manifested dizziness, headache and an elevated blood pressure of

190/100 mmHg. He was initially diagnosed of CVA. Since then he was subjected to

CBG monitoring and nursing care. He was also advised to undergo medication

therapy and to follow a prescribed diet. His final diagnosis was CVA infarct.

E. Physical Examination

November 11, 2010 (Wednesday)

General Survey:


2/17

Received patient on bed, supine position, with GCS of 12/15 (E4V2M6), with

pupil at 3mm diameter equally round and reactive to light, with an ongoing IVF of

PNSS 1L regulated at 30gtts/min at 650cc level, infusing well on the left cephalic

vein, with O2 inhalation via nasal cannula at 2-3 lpm, with NGT on left nostril intact

and kept closed. With vital signs taken as follows:

Temp = 36.2 C

PR = 60 bpm

RR = 22 bpm

BP = 180/90 mmHg

Head: Hair is uncombed, evenly distributed and black in color but there is already

presence of white hair. No presence of dandruff is found on the scalp. Skull and face

are smooth and contoured, no masses or nodules were noted. Weakness at left

cheek is noted.

Eyes: Eyebrows are symmetrical and equally distributed. Eyelashes are slightly

curved outward and equally distributed as well. Bulbar conjunctivas are transparent

with some capillaries. Palpebral conjunctivas are shiny, smooth and pink in color.

Lacrimal ducts and glands show no edema. Corneas are transparent, shiny and

smooth. Pupils are black in color. The patient has teary eyes. The patient did not

experience blurring of vision.

Ears: patient hears normal voice tone. Right and left auricles are equally aligned.

External ear canal and tympanic membrane have no discharge, with minimal

amount of dry cerumen present. No lesions noted. Pinna recoils after it is

folded. Auricles have the same color as facial skin, aligned with the outer canthus of

the eye. With good hearing ability using watch tick test.

Nose: The nares are symmetrical and the nose is uniform in color with the facial

skin. No discharges and nasal flaring noted. Absence of nodules and lesions are also

noted.


3/17

Mouth: The patients uvula is positioned on the midline of the soft palate, it is light

pink in color. The lips are dry and rough, with no presence of sores and able to

purse the lips. The patient has missing teeth. Gums light pink in color and there

is no presence of swelling. The tongue is in central position, pink in color, looks

rough and without whitish coating, can move freely from side to side and up and

down, no lesions and tenderness noted.

Neck: The neck is proportion to the body, head centered. There is no difficulty with

head mobility and head movements. The lymph nodes are not palpable and swollen.

There is no distension of neck veins. There are no masses noted upon palpation of

the thyroid gland. The patient was able to elevate his shoulders against resistance

but with weakness on the right side.

Chest and Lungs: The patients chest expansion is symmetrical, with normal

breath sounds upon auscultation on both lungs, with regular breathing pattern and

no tenderness and masses noted.

Cardiovascular: The patient has normal heart rate and normal heart sound, no

palpitations noted and full pulsations on peripheral pulse.

Abdomen: Symmetrical in appearance, there is audible bowel sounds noted and no

abnormal percussive sounds and no tenderness upon palpation.

Skin: The patient has fair complexion, with good skin turgor, no edema noted, with

some scars on some body parts.

Nails: The nails are short and clean, pale in color, there is prompt return of usual

color upon capillary refill test (< 3 seconds), no clubbing of fingernails noted.

Extremities: The patient has scars on the left and right lower extremities, no

presence of lesions or masses. The extremities are symmetrical in shape. The left

lower and upper extremities have muscle grade strength of 4/5 while the

right lower and upper extremities have muscle grade strength of 5/5.


4/17

NEUROLOGICAL ASSESSMENT

CRANIALNERVES

FUNCTION TEST EXPECTEDRESPONSE

CLIENTSRESPONSE

OlfactorySensory Sense

of Smell

Ask the client

to smell or

identify an

aromatic non-

irritating odor

such as

scents of

cologne,

vinegar and

alcohol with

each nostril

separately by

occluding it

one at a time

with eyesclosed.

Client will be

able to

identify the

aromas

correctly even

with eyes

closed.

Client was

able to

identify the

odor of

perfume and

alcohol

correctly.

Optic Sensory Sense

of Sight

Ask the client

to read the

message on

the paper at a

given

distance of 12

inches with

one eye

closed. The

same was

done with the

other eye and

Client must

see and read

the words

clearly at a

given distance

without

difficulty.

NOT ABLE

TO ASSESS


5/17

then with

both eyes

open.

Oculomotor

Motor Pupil

Constriction and

Raising of

Eyelids,

Parasympatheti

c constrict

pupils, thickens

lens

Use penlight

and ask clientto look at the

direction of

the

movement

( upward and

downward )

of the object.

Clients pupilmust also

constrict

upon

introduction

of light.

Clients pupilmust constrict

upon

introduction of

light and must

be able to

follow the

upward and

downwardmovement of

the pen

without

difficulty.

Clients pupilconstricted

when light

was

introduced.

He was able

to follow the

upward and

downwardmovement of

the pen

without

difficulty.

TrochlearMotor Eye

movement

Ask client to

follow object

(downward,

upward,

lateral and

diagonal

movement )

without

difficulty and

without

moving the

head.

The clients

eyes must

follow the

movement of

the pen with

smooth and

coordinated

movement.

Client was

able to follow

the

movement of

the pen with

smooth and

coordinated

movements.

Client did not

have any

difficulty.

Trigeminal Sensory and

Motor Jaw

Movement;

Chewing and

Ask client to

move the jaw

downward

while

Client must be

able to open

and close his

mouth and

The client

was able to

move his


6/17

Mastication;

Sensation of

skin, face,

cornea and

anterior canal

cavity

applying

resistance.

Use the tip of

the cotton to

swipe the

corneal

surface of the

eye.

move his jaw

against

resistance.

Corneal reflex

must be

elicited upon

touching the

cornea with

the cotton tip.

jaw and

open and

close mouth

while

resistance

is applied

but with

little

difficulty.

Corneal reflex

was elicited

upon

touching the

corneal

surface with

the cotton

tip.

Abducens Motor Lateral

movement of

the eye

Ask the client

to follow the

students

finger as it

moves from

side to side.

Client must be

able to follow

students

finger without

difficulty.

Client was

able to follow

the students

finger ( side

to side )

without

difficulty.Facial Sensory and

Motor

Movement of

muscles of theface; Sense of

taste of the

anterior 2/3 of

the tongue

Ask client to

raise

eyebrows,

show teethand puff the

cheeks.

Provide client

food with

varying taste

Client must be

able to raise

eyebrows,

show teethand puff the

cheeks, client

must also be

able to

identify the

The client

was able to

raiseeyebrows,

show teeth

and puff

cheeks

without


7/17

such as

sugar,

vinegar and

salt.

taste of sugar,

vinegar and

salt.

difficulty but

with

weakness at

left cheek

noted. The

students

were not

able to

assess for

the sense of

taste.

Vestibulocochlear

or Acoustics

Sensory and

Motor Hearing

and Balance

Instruct client

to listen to

the ticking of

a wrist watch

on each ear

while he is

blindfolded.

Allow client to

stand with

feet together

and arms

resting at the

sides, first

with eyes

open and

then closed.

(Rombergs

Test )

Client must be

able to

recognize the

ticking of a

wrist watch

while he is

blindfolded.

Client must

also be able to

stand with

feet together

and arms

resting at

sides, with

eyes open

then closed.

Also able to

maintain

upright

posture and

foot stance.

Client was

able to hear

the watch tick

on each ear.

The

students

were not

able to

perform the

Rombergs

test

because the

client

cannot walk

yet.

Glossopharyngeal Sensory and Instruct client Client must be The


8/17


9/17

direction, and

downward

against

resistance.

Also ask

client to

elevate his

shoulders

against

resistance.

downward

against

resistance.

Also, the

client must be

able to

elevate his

shoulders

against

resistance.

downward

against

resistance.

Also, he was

able to

elevate his

shoulders

against

resistance

but with

weakness

on the left

side.

Hypoglossal

Motor

Movement of

the tongue

Instruct client

to show the

tongue, move

it from side to

side and

protrude it in

and out.

Client must be

able to show

tongue, move

it from side to

side and

protrude the

tongue in and

out.

The client

was able to

show tongue,

move it from

side to side

and protrude

the tongue in

and out

without

difficulty.

November 11, 2010 (Thursday)

General Survey:

Received patient on bed, supine position, with GCS of 12/15 (E4V2M6), with

pupils at 3mm diameter equally round and reactive to light, with an ongoing IVF of


10/17

PNSS 1L regulated at 30gtts/min at 650cc level, infusing well on the left cephalic

vein, with O2 inhalation via nasal cannula at 2-3 lpm, with NGT on left nostril intact

and kept closed. With vital signs taken as follows:

Temp = 36.7 C

PR = 67 bpm

RR = 23 bpm

BP = 180/100 mmHg

Head: Hair is uncombed, evenly distributed and black in color but there is already

presence of white hair. No presence of dandruff is found on the scalp. Skull and face

are smooth and contoured, no masses or nodules were noted. Weakness at left

cheek is still present.

Eyes: Eyebrows are symmetrical and equally distributed. Eyelashes are slightly

curved outward and equally distributed as well. Bulbar conjunctivas are transparent

with some capillaries. Palpebral conjunctivas are shiny, smooth and pink in color.

Lacrimal ducts and glands show no edema. Corneas are transparent, shiny and

smooth. Pupils are black in color. The patient has teary eyes. The patient did not

experience blurring of vision.

Ears: patient hears normal voice tone. Right and left auricles are equally aligned.

External ear canal and tympanic membrane have no discharge. No lesions noted.

Pinna recoils after it is folded. Auricles have the same color as facial skin, aligned

with the outer canthus of the eye. With good hearing ability using watch tick test.

Nose: The nares are symmetrical and the nose is uniform in color with the facial

skin. No discharges and nasal flaring noted. Absence of nodules and lesions are also

noted.

Mouth: The patients uvula is positioned on the midline of the soft palate, it is light

pink in color. The lips are dry and rough, with no presence of sores and able to

purse the lips. The patient has missing teeth. Gums light pink in color and there

is no presence of swelling. The tongue is in central position, pink in color, looks


11/17

rough and without whitish coating, can move freely from side to side and up and

down, no lesions and tenderness noted.

Neck: The neck is proportion to the body, head centered. There is no difficulty with

head mobility and head movements. The lymph nodes are not palpable and swollen.

There is no distension of neck veins. There are no masses noted upon palpation of

the thyroid gland. The patient was able to elevate his shoulders against resistance

but with weakness on the right side.

Chest and Lungs: The patients chest expansion is symmetrical, with normal

breath sounds upon auscultation on both lungs, with regular breathing pattern and

no tenderness and masses noted.

Cardiovascular: The patient has normal heart rate and normal heart sound, no

palpitations noted and full pulsations on peripheral pulse.

Abdomen: Symmetrical in appearance, there is audible bowel sounds noted and no

abnormal percussive sounds and no tenderness upon palpation.

Skin: The patient has fair complexion, with good skin turgor, no edema noted, with

some scars on some body parts.

Nails: The nails are short and clean, pale in color, there is prompt return of usual

color upon capillary refill test (< 3 seconds), no clubbing of fingernails noted.

Extremities: The patient has scars on the left and right lower extremities, no

presence of lesions or masses. The extremities are symmetrical in shape. The left

lower and upper extremities have muscle grade strength of 4/5 while the

right lower and upper extremities have muscle grade strength of 5/5.

NEUROLOGICAL ASSESSMENT

CRANIAL

NERVESFUNCTION TEST

EXPECTED

RESPONSE

CLIENTS

RESPONSEOlfactory Sensory Sense Ask the client Client will be Client was


12/17

of Smell

to smell or

identify an

aromatic non-

irritating odor

such as

scents of

cologne,

vinegar and

alcohol with

each nostril

separately by

occluding it

one at a time

with eyes

closed.

able to

identify the

aromas

correctly even

with eyes

closed.

able to

identify the

odor of

perfume and

alcohol

correctly.

OpticSensory Sense

of Sight

Ask the client

to read the

message on

the paper at

a given

distance of 12inches with

one eye

closed. The

same was

done with the

other eye and

then with

both eyes

open.

Client must

see and readthe words

clearly at a

given distance

without

difficulty.

NOT ABLE

TO ASSESS

Oculomotor Motor Pupil

Constriction and

Raising of

Eyelids,

Use penlight

and ask client

to look at the

direction of

Clients pupil

must constrict

upon

introduction of

Clients pupil

constricted

when light

was


13/17

Parasympatheti

c constrict

pupils, thickens

lens

the

movement

( upward and

downward )

of the object.

Clients pupil

must also

constrict

upon

introduction

of light.

light and must

be able to

follow the

upward and

downward

movement of

the pen

without

difficulty.

introduced.

He was able

to follow the

upward and

downward

movement of

the pen

without

difficulty.

TrochlearMotor Eye

movement

Ask client to

follow object(downward,

upward,

lateral and

diagonal

movement )

without

difficulty and

withoutmoving the

head.

The clients

eyes must

follow the

movement of

the pen with

smooth and

coordinated

movement.

Client was

able to follow

the

movement of

the pen with

smooth and

coordinated

movements.

Client did not

have any

difficulty.

Trigeminal Sensory and

Motor Jaw

Movement;

Chewing and

Mastication;

Sensation of

skin, face,

cornea and

anterior canal

cavity

Ask client to

move the jaw

downward

while

applying

resistance.

Use the tip of

the cotton to

swipe the

corneal

surface of the

Client must be

able to open

and close his

mouth and

move his jaw

against

resistance.

Corneal reflex

must be

elicited upon

touching the

The client

was able to

move his

jaw and

open andclose mouth

while

resistance

is applied

but with


14/17

eye.cornea with

the cotton tip.

little

difficulty.

Corneal reflex

was elicited

upon

touching the

corneal

surface with

the cotton

tip.

AbducensMotor Lateral

movement of

the eye

Ask the client

to follow the

students

finger as it

moves from

side to side.

Client must be

able to follow

students

finger without

difficulty.

Client was

able to follow

the students

finger ( side

to side )

without

difficulty.

Facial

Sensory and

Motor

Movement of

muscles of the

face; Sense of

taste of the

anterior 2/3 ofthe tongue

Ask client to

raise

eyebrows,

show teeth

and puff the

cheeks.

Provide client

food with

varying taste

such as

sugar,

vinegar and

salt.

Client must beable to raise

eyebrows,

show teeth

and puff the

cheeks, client

must also be

able to

identify thetaste of sugar,

vinegar and

salt.

The client

was able toraise

eyebrows,

show teeth

with

weakness at

left cheek

noted. The

studentswere not

able to

assess for

the sense of

taste.


15/17

Vestibulocochlear

or Acoustics

Sensory and

Motor Hearing

and Balance

Instruct client

to listen tothe ticking of

a wrist watch

on each ear

while he is

blindfolded.

Allow client to

stand with

feet togetherand arms

resting at the

sides, first

with eyes

open and

then closed.

(Rombergs

Test )

Client must be

able to

recognize the

ticking of a

wrist watch

while he is

blindfolded.

Client must

also be able to

stand with

feet together

and arms

resting at

sides, with

eyes open

then closed.

Also able to

maintain

upright

posture and

foot stance.

Client wasable to hear

the watch

tick on each

ear. The

students

were not

able to

perform theRhombergs

test

because the

client

cannot walk

yet.

Glossopharyngeal Sensory and

Motor

Pharyngeal

movement;

Swallowing and

Posterior 1/3 of

the tongue

Instruct client

to open

mouth and

protrude the

tongue. An

improvised

tongue

depressor

(popsicle

stick) is then

placed on the

back portion

Client must be

able to open

mouth,

protrude

tongue and

demonstrate

gag reflex.

Client must

also be able to

swallow the

water without

difficulty and

The

students

were not

able to

perform the

test for

pharyngeal

movement

and sense

of taste for

the

posterior


16/17

of the tongue.

Ask client to

drink to know

if he is able to

swallow. Ask

client to

identify taste

of salt and

sugar.

identify taste

such as that

of salt and

sugar.

1/3 of the

tongue due

to the

absence of

tongue

depressor

and salt and

sugar.

Vagus

Sensory and

Motor

Swallowing and

Speaking

Instruct client

to speak or

say one

sentence. Ask

the client to

swallow or

drink a glass

of water.

Client must be

able to speak

clearly and

without

difficulty.

Client must

also be able to

swallow or

drink.

The patient

was not

able to

speak

clearly,

there is a

presence of

slurred

speech.Accessory Motor Head

and Shouldermovement

Ask client to

move hishead in side

to side

direction, and

downward

against

resistance.

Also ask

client toelevate his

shoulders

against

resistance.

Client must be

able to movehis head side

to side and

downward

against

resistance.

Also, the

client must be

able toelevate his

shoulders

against

resistance.

Client was

able to movehis head side-

to-side and

downward

against

resistance.

Also, he was

able to

elevate hisshoulders

against

resistance

but with

weakness


17/17

on the left

side.

Hypoglossal

Motor

Movement of

the tongue

Instruct client

to show the

tongue, move

it from side to

side and

protrude it in

and out.

Client must be

able to show

tongue, move

it from side to

side and

protrude the

tongue in and

out.

The client

was able to

show tongue,

move it from

side to side

and protrude

the tongue in

and out

without

difficulty.

after geno gram and whole PE

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Transcript of after geno gram and whole PE