Assessment TIA

8/2/2019 Assessment TIA

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A. Review of Systems

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

Integumentary

System

Skin

Inspection Skin color

uneven in

areas;

increased

creases,

wrinklelines and

skin

lesions.

Some

common

lesions

include

Seborrheic

keratosis,

Senile

purpura

and

acrochord

ons.Skin

turgor is

decreased

. Skin may

be dry,

flaky &

Skin color is

uneven in

areas.

Increased

wrinkles

and creasesnoted.

Senile

purpura

noted in

some areas

of the hands

and feet.

Skin turgor

is

decreased.

Patients

skin is dry

and thin.

The patients

skin is

normal.

There are

many age-

relatedchanges in

the skin.

Other

normal

variation

are caused

by the frail

nature of

capillaries

and

decreased

collagen

support.


2/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

Palpation

thin.

Temperatu

re: warm

but hands

and feet

may be

cool.

Patients

skin is warm

to touch.

Hand is

cool.

Hair

HEENT

Inspection General ly

black/brow

n in color.

Gray in

color for

the older

adults.

Thin hair.

Scalp may

be dry for

older

adults.

Gray

colored

hair.

-Thin hair

.

-Scalp is

smooth and

oily no

presence of

lesions

noted.

Gray coloring

occurs with

aging.

-Hair thins

with age.

(Wi lk inson &

Van Leuven,

2007)


3/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

Head/Nec

k

Eyes

Inspection

Palpation

Inspection

Normocep

hali c and

symmetric.

May have

decreased

ROM.

-Absence

of masses

and

tenderness.

(Lynn B.

2009)

-Eyes are

c lear and

bright and

parallel

alignment.

-White

sclera

-in parallel

alignment

-No

Upon

inspection

head is

normocepha

lic and

symmetrical

. Patient

was able to

turn his

head onboth sides.

No

tenderness

and swollen

lymph

nodes

noted.

-Eyes are in

parallel

alignment

-No edema

on the

eyelids.

-Eyelashes

are even ly

distributed

and curved

The patients

head and

neck is

normal.

.

The patients

eyes are

normal.


4/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

lesions

and

edema

present,

l ids move

freely

,eyelashes

are evenly

distributed

andcurved

outward,

no

excessive

tearing

nystagmus

or lid lag

-Palpebral

conjunctiv

a is

smooth,

Minimal

blood

vessels

are

present.

Pupils are

reactive to

light. Eyes

outward.

Minimal

blood

vessels are

present.

White sclera

is visible.

-Pupi ls are

equal

reactive tolight.


5/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

may be

dry and

decreased

visual

acuity and

periphery

is a

normal

variation

in theolder

adults.

Nose Inspection Nost ri ls

are patent.

Decreased

sense of

smell,

elongated

nose,

increased

nasal hair.

(P.M.Dillo

n, 2007)

The

patients

nostr ils are

patent.

Decreased

sense of

smell noted.

The patients

nose is

normal.

Anosomia-

decreased

ability to

identify and

discriminate

odors occurs

with aging.

Ears Inspection -Intact

skin, no

drainage

or lesions

-Hears the

-Upon

inspection

skin is

intact wi th

no presence

The patients

Ears are

normal.


6/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

sound

equal ly in

both ears

-Soft and

non tender

Gross

hearing

intac t but

diminished

withdecreased

pitch

discriminat

ion.

Preschyusi

s.

Increased

difficulty in

hearing

high

pitched

sounds.

(P.M.Dillo

n,2007)

of drainage

noted. Both

ears was

able to hear

the sounds

equally

during the

weber test.

The patient

was alsoable to hear

the

whispered

words and

watch tick

on both

ears. The

patient was

also able to

hear the

sound of

vibration in

the rinne

test.

Reproductive

System

Interview -No penile

discharge

-Lesions

The patient

verbalizes

no lesions

and

The patients

reproductive

system is

normal.


7/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

(P.M.Dillo

n,2007)

discharge.

Genitourinary

System

Interview No

difficulty in

urination

(P.M.Dillo

n,2007)

The patient

have fol ley

catheter

inserted.

Not normal.

Urinary

catheter is

inserted to

drain and

collect urine

from the

bladder.

Urinary

catheters are

recommended

as way to

manage urinary

incontinencean

d urinary

retention in

both men and

women.

Musculoskeletal

system

Inspection -No

tremors

Decrease in

muscle

Not normal.

Decrease in
http://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.html


8/24

System

Assessed

Technique Normal

Findings

Actual

findings

Interpretation

-Smooth

coordinate

d

movement.

-No

tendernes

s or

swelling

-No leg

cramps

(P.M.Dillo

n,2007)

strength.

Dif ficulty in

walking and

senile

kyphosis

noted.

strength and

tone may be

associated

with TIA or

stroke.

Senile

kyphosis is

most related

to aging

because of degeneration

of in vertebral

disc


9/24


10/24

Assessment on Cerebral Function

Area/ Physical

Assessment Skill

Normal Findings Actual Findings

Behavior -Well groomed, erect

posture, pleasant facial

expression, appropriate

affect.

-When we visited the patient,

he had already taken a bath a

bath and prepared himself for

the assessment. He was not

really well groomed but his

clothing was appropriate to the

setting. He was relaxed and no

unusual behavior or

movements were observed.

The facial expression of the

patient was pleasant and his

affect is appropriate for the

situation.

-Assume Senile kyphosis

posture as observed.

Level of

consciousness

(LOC)

-Awake, alert, and oriented

to time, place and person.

-Older patients may be

disoriented to time, but

note if they reorient easily.

-Client was awake alert and

oriented to time, place and

people. When we asked him

the time he took a bath he

answered 9:00 and it was

confirmed by his daughter. The

patient was able to identify his

address and the people he is


11/24

Area/ Physical

Assessment Skill


with.

Memory -Immediate, recent, and

remote memory intact.

The patients immediate and

recent memory is intact. But he

has problems with his remote

memory.

-In immediate memory, client

was able to repeat numbers

such as 2, 4, 6, 8, 10 and count

the series of numbers

backward. In recent memory,

he was able to state the things

that he did before we had

arrived. In remote memory we

asked his birth date, the patient

was able to tell us the month

and day but was not able to

remember the year. The patient

was not also able to remember

his exact age.

Mathematical -Calculative skills intact. -The patient was able to

answer correctly the simple

mathematical question/problem

such as 6+2 4+2 100-4 &

100-7.


12/24

Area/ Physical

Assessment Skill


General

knowledge and

vocabulary

-Vocabulary appropriate

and general knowledge

intact.

-The client was able to state

how many days in a week and

how many months there is in a

year. He was able to answer

general in formations such as

the name of our current

president. The patient was also

able to define apple and durian.

Thought Process -Thought process clear,

responds appropriately,

speech coherent, and

logical.

-Though process is clear.

-He had good attention span.

-Coherent and comprehensible

thought as observed.

Abstract thinking -Abstract thinking intact -The client was given a logical

question such as: What do

apple and orange have in

common? The client answered

parehas man sila lingin then

when asked for their

differences he answered ang

orange mas ma juice ang apple

wala kayo ug juice. We also

asked the client to interpret

time is gold and interpreted it

as time is important.


13/24

Area/ Physical

Assessment Skill


Judgment -Judgment intact -The client was given

hypothetical situation such as

If Noynoy was not the elected

president, who you think is the

rightful person to be in the

poition? the client answered

that it would be Erap, because

he is generous. We also asked

his opinion about the end of the

world, he said that we should

only believe in God.

-Judgment is intact.

Communication

-Speech and

language

-Speech clear, fluent, no

dysarthria, dysphasia,

dysphonia, neologisms or

circumlocution.

-The patient was fluent in

speaking, words are clear, no

speech defect as observed.

-Spontaneous

Speech

-Communication skills

intact: Spontaneous

speech, automatic speech,

motor speech, sound

recognition, auditory-verbal

comprehension, visual

recognition, visual-verbal

comprehension, writing,

and copying figures.

-We had shown 3 different

pictures to him and we asked to

identify the pictures one by one.

He identified the flower, the

watch and the microphone.


14/24

Area/ Physical

Assessment Skill


-Motor speech

-Automatic

Speech

-Sound

recognition

-Auditory-Verbal

comprehension

-Visual

-The client was able to repeat

and continue Do, re mi, fa, so,

la, ti.

-For automatic speech, we

asked him to state the days of

week in series. He stated the

days of the week starting from

Sunday to Saturday, since his

religion is seventh day

Adventist. The patient was also

able to state the days in the

vernacular.

With his eyes closed, he was

able to easily recognize the

sound of the watch.

-The client was able to follow

simple directions like standing,

raising his hand, smiling and

etc.

-The client was able to


15/24

Area/ Physical

Assessment Skill


recognition

-Visual-Verbal

comprehension

-Writing

-Copying figures

recognize things around by

sight such as pen, watch,

flower, books and etc.

-He was able to read a full

sentence and elaborated the

sentence in a comprehensible

manner.

-The client was able to write his

full name and address.

-Client was able to copy simple

figures such as triangle, circle

and rectangle.

Cranial Nerve Function

Cranial Nerves Normal Findings Actual Findings

CN I- Olfactory -CN I intact

-Sense of smell intact

The clients both nostrils were

patent. The patient was not able to

identify the odor of the coffee and

lemon with his eyes closed. He


16/24


identified the smell of coffee as

something that was burnt and

identified lemon as a candy.

hyposmia noted.CN II-Optic -CN II intact

-Visual acuity intact

Using the snellens chart without

corrective lenses. We tested his

both eyes first; the client was

able to read all the letters in the

chart. Then using a card covered

his right eye to test the left eye;

the clients visual acuity for the

right eye is 20/20. When we

tested the client had 3 mistakes

in the line; the clients visual

acuity in the left eye is 20/30.

-In Visual field, the client was

able to recognize moving object

towards the periphery.

CN III-Oculomotor

-CN III intact-Extraocular movement

intact, PERRLA direct

and consensual.

-Extra ocular movement intact,Pupils reactive and responsive to

light accommodation.

CN IV Trochlear

CN V-

Trigeminal

-CN V intact.

-Jaw muscle strength

+5, facial sensations

intact, positive cornealreflex.

The patient was able to bite down

slowly. The right side was stronger

than the left side.The patient was

also able to move his jaw side byside. The patient was able to

identify the area of the face being

touched by pointing it and was able

to identify whether the object

touched was sharp or soft; +5


17/24


facial sensations. Positive corneal

reflex was also noted.

CN VI-

Abducens

-CN VI intact The client was able to follow the

the object without turning his head.-CN VI intact

CN VII- Facial -CN intact

-Facial movements

symmetrical taste on

anterior tongue intact.

The client was able to identify the

the taste of the vinegar as sour,

sugar as sweet and salt as salty.

-For motor response, the client

was able to make face, smile,

frown, raise both eyebrows, and

puff out cheeks without signs of

problem or involuntary movements.

CN VIII-

Acoustic

-CN VIII intact

-Hearing and balance

intact

The client was able to hear

whispered voice at the distance of

1 foot with occluded tragus on the

oppposite side of the ear, we

whispered word such as one and

ten he responded correctly the

word being whispered on the left

ear but had a difficulty in hearing

the word on the right ear.

-Using a watch with second hand

the patient was able to hear the

ticking of the watch until 1 inch

away from both of the ear on the

first visit.On the second visit the

patient heard the ticking of the

watch until 3 inches.

The client was able to hear the


18/24


vibrating tuning fork in both of his

ears in during the rinne test.

The client was able to hear the

sound of the tuning fork equal in

both ears and when the tuning fork

was placed in the vertex of the

skull.

CN IX and X-

Glossopharyng

eal and Vagus

-CN IX and X intact

-Strong, clear voice,

symmetrical rise of

uvula, able to swallow

and cough. Positive gag

reflex. Taste on posterior

tongue intact.

The client has strong, clear voice

as evidenced of fluent in speaking,

no signs of speech disorders as

noted.

-The positive gag reflex was noted

by touching the posterior aspect on

the right side of the pharynx with

the tongue depressor. The patient

was able to swallow witout

difficulty. The symmetrical rise of

the uvula was also noted.

-The clients motor response is

positive in which he can move the

tongue in different movement such

as from side to side and up and

down.

CN XI-

Accessory

-CN XI intact

-Muscle strength of neck

and shoulders.

-The patient was able to shrug his

shoulders against the examiners

resistance; +3.The right side was

stronger than the left.

-In testing the strength of the neck,

the patient able to turn his head

towards the examiners hand


19/24


against the resistance and was

able to move side by side.

CN XII-

Hypoglossal

-CN XIII intact

-Full ROM of tongue,midline, no atrophy or

fasciculation.

-No atrophy of the tongue, lesions

or signs of localized infectionnoted. The patient was able to

protrude and move the tongue side

by side.

Assessing Sensory Function

Sensory Function Normal Findings Actual Findings

Light touch, pain

and temperature

-Light touch, pain and

temperatureintact upper

and lower extremities.


recognize the part of the body

being touched, by pointing out

the site. He pointed the site

easily in both distal and

proximal. The patient was

alsoable to identify that the

stimulus was light.

The client was able to identify

whether the stimulus used to


20/24


touch, was dull or sharp. We

used hair pin for sharp and the

ballpen for dull.

Deep sensation,vibratory and

kinesthetic

-Vibratory andkinesthetic sensations

intact upper and lower

extremities.

-The client was able to feel thevibration of the tuning fork when

placed on the interphalangeal

joints.

-The client was able to identify

the direction of the fingers that

the examiner moved.

Discriminatory

Sensations:

-Stereognosis

-Graphesthesia

-Two point

discrimination

Stereognosis,

graphestesia, two point

localization, and

extinction intact. -With eyes closed, the client was

able to identify the object being

touched such as pen and

umbrella.


determine the imaginary number

and written in the palm except

for letter A where the patient had

difficulty in identifying.

-The patient was able to

differentiate whether he was

touched at one or two points

simultaneously.


21/24


-Point localization

-Sensory

Extinction

With the clients eyes closed, he

was able to point out and locate

the site being touched.

-The patient was able to identify

two corresponding areas

touched simultaneously.

Assessing Reflexes

Deep tendon

Reflex


Biceps reflex -Contraction of biceps

with flexion

-+2

+1/4

Triceps reflex -Contraction of triceps

with extension at elbow

-+2

+1/4

Brachioradialis

reflex

-Flexion at elbow and

supination of forearm.

You may also notice

flexion of fingers.

+1/4


22/24

Deep tendon

Reflex


-+2

Patellar reflex -Contraction of

quadriceps withextension of knee.

-+2

+1/4

Achilles reflex -Plantar flexion of foot

-+2

+1/4

Superficial Reflex Normal Findings Actual Findings

Abdominal Reflex -Positive abdominal reflex

-May be absent in obese or

pregnant clients.

-Positive abdominal reflex

noted.

Plantar Reflex -Positive plantar reflex

-Babinski normal in infants

-Both left and right plantar

reacted to stimulus. No

babinski as noted.


23/24

Glasgow Coma Scale

Area

Tested

Best Response Points Actual

finding

Eyes Open Simultaneously

Open to Speech

Open to painful stimuli

No response

4

3

2

1

4

Speech Oriented to person, place and time

Converses but not fully oriented

Converses in disorganized manner

Vocalizes no recognizable words

No response

5

4

3

2

1

5

Motor Obeys simple commands

Does recognize local pain, but does not obey

commands

Withdraws from painful stimuli by arm flexion

Decorticate rigidity

Decerebeate rigidity

No response

6

5

4

3

2

1

6

TOTAL 15

Normal

General Survey


24/24

The patient is awake and responsive. He is alert and oriented to time,

place and person. The patient responded appropriately during the interview and

was very willing to participate in the assessment.

Date post:	06-Apr-2018
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Assessment TIA

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