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Physical Assessment (Date of Assessment: 20 January 2012) General Appearance: The patient was a medium built female wearing a clean shirt. She stands 5 tall and weighs 60kgs. He is lethargic with Glasgow Coma Scale of 14 (E3M6V4) and need closely monitoring, with headache at frontoparietal area as evidenced by guarding behaviour with accompanied by dizziness, vomiting and left sided body weakness. His vital signs were as follows: BP-170/100, PR-92 bpm, RR- 28 cpm and T- 37.1 REVIEW OF SYSTEMS Integumentary: Skin is smooth, dry, warm, brown in color, and with good skin turgor. No rash noted, edema, mass, unpleasant odor, lesion, jaundice pallor nor cyanosis noted. Hair is straight short, smooth, thin, soft with sparse black colored hair. Scalp is smooth and clean. No lesion, flakes, bruise nor lice noted. Nail is clean, thick, smooth, convex, well rounded, capillary refill of less than 3 seconds, with a nailbed angle of less than 160 degrees. Calluses noted on both feet. The surrounding cuticles are smooth, clean and intact. No inflammation and lesion noted. Head and neck Throbbing pain with guarding behaviour at frontoparietal area with a pain scale of 7/10.Dizziness was noted. No signs of recent head trauma were noted. No palpable lymph nodes, neck pain, stiffness nor enlargement of thyroid gland noted. Eyes:

Anicteric sclera, pinkish conjunctivae, pupils at 2-4 mm in size, equally round and reactive to light and accommodation with no periorbital edema on both eyes. Eye brows are symmetrical, evenly distributed, thin and light black in color.

Ears, Nose and Throat:

Ears are symmetrical, medium-sized, brown in color, smooth and clean. No lesions, foul odor, discharge, pain, itching nor change in hearing noted. Nose is smooth, brownish, and symmetric. Nasal mucosa is smooth, moist and pinkish. nares are patent. Septum is in midline position. No inflammation, pain, discharge, bleeding, deviation nor lesions noted.

Lips are dark pink, smooth, moist and symmetrical. Teeth are smooth, yellowish in color, missing both upper and lower frontal teeth and upper and lower 3rd molars. Mucosa is soft, smooth, pinkish, without lesions and unpleasant odor. Tongue is soft, reddish, smooth and no deviation noted.

Respiratory:

Not In respiratory distress with RR=28 breaths per minute, spontaneous, symmetrical chest expansion, clear breath sounds. No sputum production, cough, colds, shortness of breath, orthopnea, hemoptysis, nor intercostals retraction noted.

Cardiovascular:

Not in Cardiac distress with 92 beat per minute. No chest pain, murmurs, extra heart sounds, dysrhythmia nor thrills noted. BP= 170/100 mmHg, no edema, peripheral pulses have regular rate, strength and rhythm.

Gastrointestinal:

Rounded, soft, flabby, normoactive bowel sounds. No abdominal/ rectal pain, scar, lesion, bruise, bleeding, nor tarry stools noted.

Genitourinary/Reproductive:.

Yellowish urine of 500-1000 ml per shift when an indwelling Foley catheter was inserted upon transfer to 4A. No nocturia, hernia, unusual discharge, hemorrhoids, scars, lump, nor rashes were noted on the Genital area.

Neurological: a. Cranial Nerve I intact

II III-IV-VI V VII VIII IX-X XI XII

intact visual acuity Pupils at 3-4mm ERRLA, no periorbital edema on both eyes with corneal reflex with facial symmetry Intact hearing gag reflex present unable to shrug left shoulder no tongue deviation

b. Sensory Function

Sensations are not equally felt on both upper and lower extremities. Hypotonic reflex (+1) noted on both Left upper and lower extremities. (-) Babinski reflex was noted MOTOR R 5/5 5/5 L 0/5 0/5 R 100% 100% SENSORY L 60-70% 60-70%

c. Reflexes

Musculoskeletal:

No ROM noted on both left upper and lower extremities