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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:
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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.