Physical Examination

General Survey

The patient is conscious, coherent, oriented to time and place, responsive, no slurring of speech. He has a medium body
built with steady gait, good grooming, good posture, afebrile, ambulatory, and is not in apparent cardio-respiratory distress. No
gross deformities noted.

Integumentary:

Patient’s skin is brown in color, smooth, warm to touch, with good skin turgor and elasticity. Hair is black, short and well
distributed. No scars, hyperpigmentation or hypopigmentation were noted. Nails are short. No clubbing, no swelling of nail bed, no
cyanosis with good capillary refill of less than 2 seconds was noted.

Vital Signs:

Temp: 36.7 °C (Left Axilla) RR: 22 cpm HR: 98 bpm BP: 112/82 mmHg (Left arm, sitting)

HEENT:

Cranium
The hair is black in color, abundant, well distributed and dry texture. Scalp is slightly movable along with the cranium, no
lesions, and no lice. The cranium is normocephalic, symmetrical and has no deformities. No tenderness, no masses. Temporal arteries
are not visible but palpable with weak pulsation.

Face
The face is symmetrical, skin is brown in color, loose skin and no lesions. There is no abnormal facial expression and no
involuntary movement noted. Eyebrows are black and well distributed. Eyelashes are black, both upper and lower lashes were
outwardly oriented. Eyelids have no lesions, no edema and negative for lid lag. No ptosis. Eyeballs have no sign exophthalmos and
enophthalmos. Periorbital area are not sunken, no swelling, hematoma, or lid lag observed in the eyelids. Conjunctivas are pale in
color, no swelling and hematoma. Sclera is whitish in color and no lesions noted. Cornea is transparent bilaterally and no foreign body.
Iris is convex and brown in color. Pupils are round, symmetrical and about 3mm upon constriction with normal accommodation and
reactive to both direct and consensual reflex. Both lenses are transparent and no opacity noted. On palpation, no firmness and eyeball
tension noted. Fundoscopy was not performed,

Ears
The patient has normal set of ears, symmetrical, no deformities, no lesion and no tenderness over auricles and mastoid.
External auditory canal is patent; walls are pinkish to pale in color, with abundant cerumen and no foreign bodies. Otoscopy was not
done.

Nose
Nose is symmetrical and blunt, no flaring of ala nasi. Vestibule is patent pinkish in color, no secretions and no bleeding. Nasal
septum is straight at the midline and no perforation. No tenderness of paranasal sinuses upon palpation. No edema, swelling, or
abnormal secretions noted.

Mouth and Throat

Lips are pinkish to pale, symmetrical, and dry with no lesion. Buccal mucosa is pale and dry, no lesion and swelling. Tongue is
mobile, no hypertrophy and atrophy, midline in position upon protrusion and retraction, no involuntary movement and can move
without difficulty. Patient has incomplete set of teeth and dental carries was noted. Gingivas are pale and no bleeding or recession
noted. Palate is slightly pale with no lesions. Uvula is in midline. Tonsils are small and pink, no enlargement and swelling was noted.
Posterior pharyngeal wall is pinkish and no lesions and swelling.

Neck
Skin is brown in color, no deformity, symmetrical. Trapezius and sternocleidomastoid are well developed muscles, no
deviations noted. ROM not performed. Trachea is in the midline. The thyroid gland is not visible but palpable with no tenderness,
moves with deglutition. No tonsillar, submental, submandibular, preauricular, posterior auricular, occipital, superficial cervical, deep
cervical, posterior cervical and supraclavicular lymph adenopathy.

Chest and Lungs

Upon inspection; skin is brown in color, warm to touch, no visible subcutaneous blood vessel with no contraction of accessory
muscle. Anterior thoracic wall is elliptical in shape, symmetrical in both sides, has no bone deformities, no widening of intercostal
spaces, no retractions. Anterior posterior is less than transverse diameter with AP diameter to lateral diameter ratio of 1:2. Respiratory
rate is 22 cpm. Inspiration is longer than expiration.
Upon palpation no masses or tenderness noted, and symmetrical lung expansion. There is decrease tactile fremitus on the
left lung. Resonant on all lung field. Decrease breath sound in left lung, wheezes heard in left upper and right upper lobe, and crackles
heard in left lower lobe. Negative for egophony, bronchopony and whispered petriloquy.

Cardiovascular System

Precordium is adynamic, without bulging or visible pulsations; no jugular vein pulsation; apical beat is at the 5 th ICS, left midclavicular
line. S1 is best heard at the apex while the S2 is best heard at the base. No S3, S4, physiologic splitting, or murmurs heard. No
tenderness, no masses, no heaves, thrills and lifts noted; Heart Rate is 98 beats per minute; heart rhythm is noted to be regular; no
murmurs, gallops or extra heart sounds noted; carotid pulse is strong, regular and equal, without bruits; radial, brachial pulses are
strong, regular and equal.

Abdomen

The abdomen is globular and symmetrical with an abdominal circumference of 73cm. Skin is brown in color, no noted striae; no
visible masses, peristalsis and pulsation. Umbilicus is inverted, with normoactive bowel sounds of 9/min at the right lower quadrant.
No bruit heard over the abdominal, renal and iliac arteries. All quadrants are tympanic, no areas of dullness. The liver, spleen, and
kidneys are not palpable upon light and deep palpation. Negative for costovertebral angle tenderness. Abdomen is soft and no
palpable masses, no organomegaly. No noted tenderness.

Spine and extremities

Hands and wrist:
Nail beds are symmetrical on the left and right, no clubbing of fingers with pale nail bed on both hand. No noted lesions, swelling,
redness, tenderness, palpable mass, or gross deformities. No noted atrophy or hypertrophy of muscles. Bilateral active full range of
motion i.e. flexion, extension and adduction of finger, apposition of thumb for both hands; has no ulnar or radial deviation of the
wrist.

Forearm and Elbow:

No noted lesions, swelling, redness, tenderness, palpable mass, and gross deformities. Muscles are symmetrical with no noted
atrophy or hypertrophy of muscles. No crepitus or tenderness noted upon palpation of radius and ulna. Radial and Brachial pulses
are strong and equal. Bilateral active full ROM as to flexion, extension, pronation, and supination. Arm and forearm circumference
were not assessed.

Shoulder Joints:
Cannot perform full ROM as to adduction, abduction, external and internal rotation on the left shoulder due to the test tube that
was placed on the left mid axillary line. No atrophy, swelling, crepitus, masses, lesions, or nodules noted on both shoulders.

Cervical Spine and Back:

Midline Vertebrae is intact and concave curvatures. No nodules, swelling, or tenderness upon palpation. No atrophy or
hypertrophy of muscle. Full ROM of spine was noted.

Hip and Lower Limb:

 Bilateral active full ROM as to flexion, extension, external and internal rotation; lower limbs are symmetrical; no atrophy or
hypertrophy noted. Normotonic on both right and left lower extremities. Thigh circumference was not assessed. No swelling,
crepitus, masses, lesions, or nodules noted on both hips.

Knees:
Bilateral active full ROM as to extension, flexion; symmetrical, no crepitus, atrophy, masses, lesions, or nodules noted on both
knees.

Ankle and Foot:

Bilateral active full ROM as to eversion, inversion, dorsiflexion, and plantar flexion; symmetrical, normotonic, no atrophy, no pitting
edema, or nodules noted upon palpation on both ankles and foot.

Toes and Soles:

Bilateral active full ROM as to flexion, extension, abduction, and adduction; no inflammation of nail folds noted. Pedal arc is
present on both feet. Symmetrical, normotonic, no atrophy, crepitus, masses, lesions, or nodules noted on both toes and soles.

Neurologic examination

A.Cerebral Function

The patient is conscious and coherent. Speech is fluent, normal in terms of tone and speed and no slurring of speech.
Patient is able to follow simple and complex commands, name objects and can repeat sentences. The patient is well oriented as to
time, place and person, is able to do simple calculation, and has intact recent, remote and immediate memory. She also has good
abstract thinking, knows general information and has good judgement.

B.Cranial Nerves

Olfactory (I) nerve: Patient was able to detect and identify the smell. Patency of each nostrils was not assessed

Optic (II) nerve: Patients visual acuity is 20/200 on both eyes. Has reading glasses but unrecalled grade. No visual field defect

Optic nerve (II) and Oculomotor (III) nerve are intact; pupils are 2 to 3mm in sized and are equal, round and reactive to light
accomodation. There is an equal pupillary reaction to direct and consensual light reflex

Occulomotor (III), Trochlear (IV) and Abducens (IV) nerve are intact, normal extraocular muscle movement. Patient is able to follow
the fingers using the “H” pattern movement. Negative for nystagmus

Trigeminal (V) nerve is intact; patient can feel pinprick / brushing sensation on her face. Corneal reflex was not assessed. No
atrophy or fasciculation of mastication muscles and normotonic; muscle tension upon teeth clenching symmetrical and equal face
and was able to demonstrate normal tone and force in the muscles of mastication.

Facial (VII) nerve is intact, Patient was able to demonstrate proper facial expressions by raising both eyebrows, wrinkle forehead,
close both eyes tightly, smile, frown, and purse lips without difficulty. Taste sensation was not assessed.

Acoustic (VIII) nerve intact, patient was able to localized source of sound from rubbing fingers and repeat whispered words on both
ears. Weber’s and Rinne’s Test were not assessed.

Glossopharyngeal (IX) and Vagus (X) nerve is intact, Uvula is seen in the midline and there is equal and normal pharyngeal wall
movement. Speech is normal in tone and modulation there are no hoarseness, dysphonia, and dysarthria heard in terms of vagus
nerve. Gag reflex was not assessed.

Accessory (XI) nerve is intact, patient is able to shrug and elevate shoulders against resistance and bow and rotate his head against
resistance; no atrophy or fasciculation of muscles, and muscles are normotonic, muscle tension symmetrical.

Hypoglossal (XII) nerve is intact; patients tongue is found midline, symmetrical when protruded, no atrophy, fasciculation’s or
involuntary movements noted. Able to move her tongue from side to side.

C. Motor Testing
 On inspections no visible muscle atrophy, hypertrophy, involuntary movements and fasciculation’s noted. Muscle tone is
normal, no spasticity, rigidity and hypotonicity noted. With good muscle strength on the upper and lower extremities. Muscle
strength index of 5/5.

D. Cerebellar Function

Coordination
Patient does not have upper extremity dysmetria, able to execute finger-nose test and rapid alternating movement
smoothly and bilaterally. Patient was also able to demonstrate heel to shin test. Tandem walking test was not assessed.

Reflexes
Biceps and triceps tendon reflex are 2+. Other tendon reflexes were not assessed.

Sensory Function
Patient has normal peripheral sensation, able to sense pain symmetrically in dermatome areas. Able to distinguish between
sharp and dull sensation on both upper and lower extremities; however cannot determine properly 2 point discrimination.

Meningeal sign
Not assessed