PHYSICAL ASSESMENT

Mental Status Level of consciousness: Patients is awake, alert and well-oriented Head and Neck: Hair is evenly distributed , there is no presence of bleeding, lesions or palpable masses There is no presence of tenderness in the head Carotid arteries are equally palpable There is also no presence of any hum or bruit upon auscultation

Eyes, Ear s, Nose, and Sinus Eyes: Eyes are symmetrical, conjunctiva. Subconjunctiva and sclera is pinkish in color with no presence of bleeding or lesions in the area, Nose: Nostrils are both patent, there are no presence of any signs and symptoms of upper or lower respiratory tract infection Frontal, sphenoidal and maxillary sinuses are palpable Ears: Clients hearing acuity is evenly distributed Mouth: Gums are pinkish in color with no presence of lesions or any oral sore

Posterior Thorax: Shoulder strength is bilateral and equal, muscle strength 5/5 Lung Fields are equally resonant; Tactile fremitus : Normal PR: 67, RR 12, BP 90/70 ; No adventitious sounds were heard upon auscultation

Anterior Thorax: Breasts are symmetrical and there is no presence of dimpling or retractions Bowel sounds: present ever 5-10 seconds. Upon percussion abdomen was found to have resonance and dullness sound was heard over the liver

Upper and Lower extremities: Muscle strength of upper extremities is 5/5 Active flexion with resistance Active extension with resistance Able to perform the cross-over hand grip strength Muscle strength of lower extremities is 5/5 Active right and left knee flexion with resistance Active right and left knee extension with resistance Theres is no presence of edema Client has done the rombergs test perfectly and has a good posture and gait

THOROUGH NEUROMUSCULAR ASSESSMENT

Cerebral Function:

Patient is alert, can recall recent memories and remote memories. Patient responds to pain. . Glasgow Coma Scale Score: 16 EYE OPENING:4 Patient opens the eyes spontaneously VERBAL RESPONSE :5 Patient is oriented and responds clearly in a conversation MOTOR RESPONSE: 6- Obeys commands

Cranial Nerves.

CN1: Patency of the nose: normal Can identify the aroma correctly.

CN2: Can only read the snellens chart up to the 5th row Pupillary reflex: PERLA

CN3, 4, 6: Patients eyes are able to follow the direction of the penlight that follows the shape of H.

CN5: Facial skin can feel the sensation of the brush and pin.

Muscles for mastication: normal

CN7: Can recognize the taste of sugar,salty, sweet and sour. Facial symmetry was noted.

CN8: Patient can hear and feel the vibrations of the tuning fork.

CN9 & 10: Gag reflex is present. Soft palate, rising after instructing the patient to say Ah

CN11: Patient resisted the force that was applied on his shoulders.

CN12: Tongue symmetry was noted.

Motor Function: Muscle tone : 3/5 Muscle Strength: 5/5

Cerebellum Function:

Coordination of hands was noted. Can perform finger to nose test.

Brainstem Motor Function: Eyes appear to move opposite to the movement of the head.

Sensory function: Can differentiate smooth and rough surface. Body symmetry was noted. Can recognize hot and cold sensations, blunt and sharp objects. Can Identify objects placed in his hands.