I.

PHYSICAL EXAMINATION

General:
The patient appeared weak and in sitting position when examined. He is unresponsive, but
cooperative. He is not neatly dressed, well-groomed, with body odor. He is febrile, and not in
cardiopulmonary distress.

Vital Signs:
Temp: 37.9 °C
BP: 110/70 mmHg (Right arm)
PR: 96 bpm
HR: 96 bpm
RR: 22 cpm

Integument:
Skin is dark fair in complexion. Several hyper pigmented scars on both lower extremities
near the ankle were noted. No suspicious nevi, petechiae, or ecchymosis. With good skin
turgor. Nails slightly pale with good capillary refill. No clubbing, ridges, breaks. Multiple
cutaneous neurofibromata were noted mostly in the head and neck, torso, and upper
extremities.

Head:
Skull is normocephalic/atraumatic. With lumps noted at the occiput. Has dandruff on scalp.
Hair is dry, average in texture and black in color with even distribution admixed with gray
hairs. Face is symmetrical with no involuntary movements, edema, and masses.

Eyes:
Symmetrical eyebrows with evenly distributed hair. Brownish sclera. Pale conjunctiva.
With adequate closure of the eyelids and normal outward projection of the eyelashes. Corneal
reflections on both eyes are symmetrical with opacities in the right eye. No scars and
ulcerations. Lisch nodules were noted in the Iris. Pupils symmetrical with diameter of 3 mm,
equally round and reactive to light and accommodation. Visual acuity 20/30 bilaterally. Intact
visual fields. Full EOM with no field cuts. Normal conjugate gazes. No nystagmus and lid lag.
With good convergence on both eyes.

Ears:
Symmetrical alignment. Firm pinnae. No pain. Modest amount of wax. Intact tympanic
membranes and canals. Hearing acuity intact.

Nose and Sinuses:

Pinkish and dry nasal mucosa. No abnormal discharge. Nasal septum midline. Turbinates
red and not inflamed. Bulging of right nostril due to tumor. No tenderness over sinuses.

Mouth and Throat:

No halitosis. Lips symmetrical, dark, and dry, with cutaneous neurofibromatosis on
borders. Intact oral mucosa. Gums pinkish with no bleeding. Intact hard palate. Teeth
complete, some with dental carries. Tongue is pinkish and smooth with symmetric protrusion.
Lingual frenulum and uvula midline. Pharynx without exudates. Tonsils not inflamed. No oral
aphthae noted.

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 Neck:
Neck supple. No palpable lymph nodes. Trachea midline and moves with deglutition.
Thyroid glands not palpable. No carotid bruits.

Chest and Lungs:

Thorax is symmetric. No lagging upon expiration. Affected with cutaneous
neurofibromatosis on both nipples. No tenderness over the left chest and back. Confirmed
symmetrical chest expansion. Normal tactile fremitus on both sides. Resonant on both lungs.
No adventitious breath sounds heard on both lung fields.

Heart:
No precordial bulging and visible pulsations. PMI at 5th ICS MCL. No palpable heaves. No
thrills nor heaves. With fast pulsations upon palpation. No S3 and S4. No pericardial rubs. No
murmurs.

Abdomen:
Abdomen is symmetrical and flat. Cutaneous neurofibromatosis all over the abdominal
area, no visible pulsations, masses, and peristalsis. Hypoactive bowel sounds with 5 clicks/min.
Tympanitic on all quadrants. Liver span approximately 7 cm. Soft and non-tender. No palpable
masses or hepatosplenomegaly. Spleen and kidneys not felt. No costo-vertebral angle (CVA)
tenderness.

Extremities:
Equal in size and length, cutaneous neurofibromatosis present all over the extremities, no
deformities, no trauma, no visible pulsations, no varicosities. No edema on both lower
extremities but with hyper pigmented scars on both legs. Full peripheral pulses, grade +2

II. NEUROLOGIC EXAMINATION

A. Mental Status
Patient is appears weak, relaxed, and cooperative. He is not well-groomed with affect
within normal range. Speech is clear, fluent with good repetition, comprehension, and naming.
Thought processes are coherent, insight is good.

B. Cranial Nerves
CN I – Able to identify coffee
CN II – Pupils are 3mm and reactive to light and accommodation. Normal direct and consensual
reflexes.
CN III, IV, VI – EOM intact with good convergence.
CN V – Corneal responses intact. Loss of facial sensation in all branches of the trigeminal
nerve
CN VII – Face is symmetric with normal eye closure and smile.
CN VIII – Intact
CN IX and X – Palate elevates symmetrically. Phonation not tested.
CN XI – Intact head turning and shoulder shrug.
CN XII – Tongue midline with normal movements and no atrophy.

C. Motor function
Muscle strength is full on upper extremities with normal muscle bulk and tone.
Muscle strength on lower extremities are weak 4/5 bilaterally.

D. Sensory
On upper extremities, light touch, pinprick, and position sense are intact. Two-point
discrimination are normal. On lower extremities, light touch is not sensed and sensation to pinprick
is absent. Two-point discrimination is also impaired.

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E. Reflexes
Biceps Triceps Brachioradialis Knee Ankle Plantar
R 2+ 2+ 2+ 2+ 2+ 2+
L 2+ 2+ 2+ 2+ 2+ 2+

Pathologic Reflexes
(-) Babinski reflex
(-) Ankle clonus
G. Cerebellar
RAMs and fine-finger movements intact. No abnormal extraneous movements. Posture is
normal.

H. Meningeal Signs:
(-) Brudzinski’s sign
(-) Kernig’s sign

I. Autonomics:
No bladder or bowel incontinence.