PRESENT STATEPHYSICAL EXAMINATIONDay 1: September 16, 2015 (1:15 pm)

GENERAL APPEARANCE: Seen patient on the bed awake, alert, responsive, and coherent with ISA on his left arm, with the following vital signs: BP=130/70mmHgPR=102bpmRR=36cpm Temperature=37.1°C/axilla

ANTHROPOMETRIC MEASUREMENTS:Weight: 47kg (103.4lbs)Height: 4’6” (1.39m)BMI: 24.32 (overweight)IBW: 42.7kg (94 lbs)BMI Categories:

      Underweight = <18.5      Normal weight = 18.5–24.9      Overweight = 25–29.9      Obesity = BMI of 30 or greater

SKIN: Dark brown, evenly colored skin tone. Skin is dry and warm. Skin is thin with calluses noted on plantar surface of both feet. Skin pinches easily and immediately return to its original position. Hematomas 15 mm in diameter are seen on both upper and lower extremities due to previous IV injection site. With ISA on his left hand .

SCALP&HAIR: Hair is black, clean, slightly oily, and smooth and firm without parasites /lice infestations noted. Scalp is clean and dry. Even, prominent fine hair on arms, hands, thigh and legs.

NAILS: Upper and lower extremities has transparent nail with pinkish nail beds. Nails are round with 160° nail base. Hard, immobile, smooth and firm nail plate is firmly attached to nail bed. Fingernails are long with black-dirt deposits.

HEAD & FACE: Symmetric, round, erect and in midline. Hard and smooth without lesions or lumps. Head is still and upright without abnormal facial movement. Temporomandibular joint has no swelling or tenderness, mouth opens and closes fully.

EYES: Eyeballs are symmetrically aligned in sockets without protruding or sinking. Eyebrows are the same with hair color, symmetric and evenly distributed. Lid margins are moist and pink. Lashes are long, evenly spaced and curled outward. Bulbar conjunctiva is clear, moist and smooth with tiny vessels visible. Sclerae is white. Palpebral conjunctivae are pink, moist and free from swelling and lesions. Cornea is transparent, moist and without opacities. Lens are clear. Pupils are equally round and reactive to light

and accommodation (PERRLA). Positive corneal light reflex, reflections of light noted at same spot on both eyes. Full extraocular movements. Readssome writings on the notebook within 12-14 inches without difficulty. Client was able to read out bed number illustrations located at other end of the ward out loud without squinting or difficulty.EARS: Equal in size bilaterally. Pinna is in line with lateral canthus of both eyes. External ears are smooth without lesions, color consistent with the facial color and no discharges noted. Small amount of moist, yellow cerumen was noted on both ears.

NOSE: Color consistent with the rest of the face, smooth and symmetric without tenderness and discharges noted. Able to sniff and blow through each nostril. Nasal mucosa is dark pink, moist and free of exudates. Nasal septum at midline, intact and free of ulcers or perforations. Clear frontal and maxillary sinuses upon transillumination and are non-tender to palpation and percussion.

MOUTH:Lips are pinkish, rough and dry without lesions or swelling. Gums are pink, moist and firm with tight margins to the teeth, no lesions, redness and swelling noted. Buccal mucosa is pinkish, smooth and moist without lesions. Tongue is moist, pinkish at midline without lesions,

nodules or fasciculations, papillae present on dorsal surface. Smooth, pink and hard palate with firm transverse rugae. Uvula is pinkish, moist, hang freely in midline without redness or transudate. Tonsils are pink, symmetric without exudates and swelling. Gag reflex is intact.

NECK: Symmetric with head centered and without bulging masses. Full range of motion, smooth and contracted. Trachea is in midline. Thyroid gland arepositioned midline, smooth, firm and non tender. Lymph nodes are not palpable.

CHEST & LUNGS: Scapulae symmetric & nonprotruding. Anteroposterior is less than transverse diameter. Sternum at midline and straight. Ribs slope downward with symmetric intercostals spaces. Depth, rhythm & quality of respiration isshallow with regular pace, relaxed, effortless and quiet use of accessory muscle.Respirations areirregular RR = 36 cpm (Normal value = 2 years to 10 years: 20-28 cycles per minute). No retractions and bulging noted. Bronchial breath sounds were heard over the trachea, bronchovesicular breath sound over the primary bronchi and vesicular breath sound over the lung fields. No adventitious sounds noted. Fremitus is symmetric and easily identified in the upper

regions of the lungs. Chest expansion was 5cm. Percussion tone is resonance all over the lung fields.Crackles were heard on the right lung.Egophony soft and muffled with distinguishable letter “E”. Bronchophony is soft, muffled and indistinct. Whispered pectoriloquy is distant and very muffled.HEART & PERIPHERAL VASCULATURE: Apical pulse at fifth intercostals space, left midclavicular line with a rate of 105bpm. Rhythm and pace is regular.S1 sound is distinct and heard best at the apex (mitral valve). S2 sound is distinct and heard best on the base (pulmonic & aortic valve). No extra heart sounds, murmurs and varicosities noted.Presence of pitting edema on both feet with a grade of +1.CAPILLARY REFILL TIME: pink tone returns immediately to blanched nail beds when pressure is released.

Upper extremities (R) pinkish; <1 sec

Upper extremities (L) pinkish; <1 sec

Lower extremities (R) pinkish; <1 sec

Lower extremities (L) pinkish; <2 secs

PERIPHERAL PULSES:(R) Temporal 101 +2 Carotid 103+2Brachial 104+2Radial 101+3Popliteal 101 +2 Posterior tibialis 101+2Dorsalispedis 103+2

Pulse Amplitude Scale0 = Absent+1 = Weak+2 = Normal+3 = Increased+4 = Bounding

ABDOMEN: Rounded and symmetric without bulges. Striae not noted. Umbilicus is at midline, depressed and without bulging. Soft gurgles and clicks heard all throughout the quadrants of the abdomen. Percussion tone is tympany. Girth is 92 cm. No fluid wave is transmitted. The borders between tympany and dullness remain relatively constant throughout position changes.

Bowel sounds: (clicks/minute)(R) (L)

06 12

34 24

RECTUM & GENITALIA: Assessment not conducted

BACK & EXTREMITIES: Uneven weight bearing is evident. Wide-based gait is noted. Client cannot completely stand on his own because client claims his body, especially his feet, is still weak. Posture is erect without exaggerated curvature of cervical, thoracic and lumbar spine. Spine is straight. Client was able to perform full ROM on his both lower extremities and on his left upper extremity but with sligh but with slight difficulty.Upper and lower extremities are symmetric.

Muscle strength: (R) (L)5/5 4/5

4/5 4/5

Scale:5 – Full ROM against gravity, full resistance4 – Full ROM

against gravity, some resistance3 – Full ROM with gravity2 – Full ROM with gravity eliminated (passive motion)1 – Slight Reaction0 – No Reaction

NEUROLOGIC ASSESSMENTMental Status/ Cerebral Function:Client is awake, responsive, alert, and cooperative, appears to be relaxed, and maintains eye contact. Client states nickname “Marky” when asked, states “Lawaan Elementary School” when asked for the name of his school and states “Grade 3” when asked for his grade leve. Client listens and can follow directions.In the Glasgow Coma Scale, client scores 15 observed by as follows: eye opening response is spontaneous (rated 4); oriented

verbal response (rated 5); obeys verbal commands (rated 6).GCS scoring:Eye response:1 - no eye opening2 - eye opening in response to pain stimulus3 - eye opening to speech4 - spontaneous eye openingVerbal Response:1 - no verbal response2 - incomprehensible sounds3 - inappropriate words4 - confused5 – oriented

Motor response:1 - no motor response2 - extension to pain3 - abnormal flexion to pain4 - flexion/withdrawal to pain5 - localizes to pain6 -  obeys commands

Motor/Cerebellar FunctionsClient can perform rapid-alternating movements. Client was able to perform finger-thumb test on the right and left hand. Client can touch his nose with his right and left hand. Client needs assistance in standing or ambulating.

Sensory FunctionClient can differentiate between dull and sharp objects on both arms as well as the cheeks.

Cranial Nerve TestingCN 1 (Olfactory): Correctly identifies scent of banana peelCN 2 (Optic): reads writings on the notebbok at approximately 12-14 inches on both eyesCN 3, 4 &6 (Oculomotor, Trochlear, Abducens): full extraoccular movements, (+) PERRLACN 5 (Trigeminal): Corneal reflex present; clenches teethCN 7 (Facial): Able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purses lips, raise eyebrows &close eyes against resistance.CN 8 (Vestibulocochlear): Whispered words heard within 2ft both ears. CN 9 & 10 (Glossopharyngeal &Vagus): Uvula & palate rise symmetrically when client says “ah”; gag reflex present; swallows without difficulty.CN 11 (Spinal Accessory): Equal shoulder shrug against resistance; turns head in both directions against resistance.CN 12 (Hypoglossal): Protrudes tongue in midline, able to push tongue depressor in left & right side of the mouth without difficulty

DEEP TENDON REFLEXES: Biceps

(R) +2

Grading Deep Tendon Reflexes+4 –

(L) +2Triceps

(R) +2

(L) +2Brachioradialis(R) +2(L) not assessed due to ISA attached

Patellar (R) +2 (L) +2

Achilles(R) +2 (L) +2

hyperactive, very brisk, rhythmic oscillations (clonus); abnormal and indicative of disorder+3 – more brisk or active than normal, but not indicative of disorder+2 – normal, usual response+1 – decreased, less active than normal0 - no response

Day 2: September 17, 2015 (2:30pm)GENERAL APPEARANCE: Seen patient on the bed awake, alert, responsive, and coherent with ISA on his left arm, with the following vital signs: BP=130/70mmHgPR=104bpmRR=40cpm Temperature=37.4°C/axilla

SKIN: Dark brown, evenly colored skin tone. Skin is dry and warm. Skin

is thin with calluses noted on plantar surface of both feet. Skin pinches easily and immediately return to its original position. Hematomas 15 mm in diameter are seen on both upper and lower extremities due to previous IV injection site. With ISA on his left hand . .

CHEST & LUNGS: CHEST & LUNGS: Scapulae symmetric & nonprotruding. Anteroposterior is less than transverse diameter. Sternum at midline and straight. Ribs slope downward with symmetric intercostals spaces. Depth, rhythm & quality of respiration isshallow with regular pace, relaxed, effortless and quiet use of accessory muscle.Respirations areirregular RR = 36 cpm (Normal value = 2 years to 10 years: 20-28 cycles per minute). No retractions and bulging noted. Bronchial breath sounds were heard over the trachea, bronchovesicular breath sound over the primary bronchi and vesicular breath sound over the lung fields. No adventitious sounds noted. Fremitus is symmetric and easily identified in the upper regions of the lungs. Chest expansion was 5cm. Percussion tone is resonance all over the lung fields.Crackles were heard on the right lung.Egophony soft and muffled with distinguishable letter “E”. Bronchophony is soft, muffled and

indistinct. Whispered pectoriloquy is distant and very muffled.HEART & PERIPHERAL VASCULATURE: Apical pulse at fifth intercostals space, left midclavicular line with a rate of 105bpm. Rhythm and pace is regular.S1 sound is distinct and heard best at the apex (mitral valve). S2 sound is distinct and heard best on the base (pulmonic & aortic valve). No extra heart sounds, murmurs and varicosities noted.Presence of pitting edema on both feet with a grade of +1.

ABDOMEN: Rounded and symmetric without bulges. Striae not noted. Umbilicus is at midline, depressed and without bulging. Soft gurgles and clicks heard all throughout the quadrants of the abdomen. Percussion tone is tympany. Girth is 84 cm.No fluid wave is transmitted. The borders between tympany and dullness remain relatively constant throughout position changes.

BACK & EXTREMITIES: Wide-based gait is noted. Client can already completely stand on his own.Posture is erect without exaggerated curvature of cervical, thoracic and lumbar spine. Spine is straight. Client was able to perform full ROM on his both lower extremities and upper extremities.Upper and lower

extremities are symmetric.Muscle strength: (R) (L)5/5 5/5

5/5 5/5

Scale:5 – Full ROM against gravity, full resistance4 – Full ROM against gravity, some resistance3 – Full ROM with gravity2 – Full ROM with gravity eliminated (passive motion)1 – Slight Reaction0 – No Reaction