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A.

Review of Systems System Assessed Integumentary System Skin Inspection Technique Normal Findings Actual findings patients is are Interpretation

Skin color Skin color is The uneven areas; increased creases, wrinkle lines skin lesions. Some common lesions include keratosis, Senile purpura and acrochord ons.Skin turgor is decreased . Skin may be flaky dry, & in uneven areas. Increased wrinkles and creases and noted. Senile purpura noted in some areas of the hands and is decreased. Patients skin is dry and thin. feet. turgor in skin

normal. There related changes in the Other normal variation are caused by the frail nature and decreased collagen support. of capillaries skin. many age-

Seborrheic Skin

System Assessed

Technique

Normal Findings thin.

Actual findings

Interpretation

Palpation Temperatu re: and may cool. warm feet be but hands

Patients skin is warm to Hand cool. touch. is

Hair

Inspection

Generally black/brow Gray color the Thin adults.

Gray colored

Gray coloring occurs aging. -Hair with age. (Wilkinson & is Van no Leuven, thins with

n in color. hair. in -Thin hair for . older -Scalp

hair. smooth and 2007)

Scalp may oily older adults. lesions noted.

be dry for presence of

HEENT

System Assessed Head/Nec k

Technique Inspection

Normal Findings Normocep halic May ROM. -Absence and tendernes s.

Actual findings Upon

Interpretation The head is neck normal. and patients and is

and inspection have normocepha lic . turn head symmetrical Patient

symmetric. head decreased

of masses was able to his . on

both sides. B. No tenderness and swollen lymph nodes noted.

Palpation

(Lynn 2009)

Inspection Eyes

-Eyes clear parallel

are -Eyes are in and parallel -No on eyelids. -Eyelashes evenly curved distributed and edema the

The eyes

patients are

bright and alignment alignment. -White sclera alignment -No

normal.

-in parallel are

System Assessed

Technique

Normal Findings lesions and edema present, lids freely ,eyelashes distributed and curved outward, no excessive tearing nystagmus or lid lag -Palpebral conjunctiv a smooth, Minimal blood vessels are present. Pupils are reactive to light. Eyes is

Actual findings outward. Minimal blood vessels are White sclera is visible. are to equal reactive light.

Interpretation

move present.

are evenly -Pupils

System Assessed

Technique

Normal

Actual

Interpretation

Findings findings may be dry visual acuity and periphery is normal variation in older adults. the a and decreased

Nose

Inspection

Nostrils Decreased sense smell, elongated nose, increased nasal hair. (P.M.Dillo n, 2007)

The nostrils

The nose

patients is

are patent. patients of patent. Decreased sense smell noted.

are normal. Anosomiadecreased of ability identify odors discriminate occurs with aging. to and

Ears Inspection -Intact skin, drainage or lesions -Upon no inspection skin intact with The Ears is normal. patients are

-Hears the no presence

System Assessed

Technique

Normal Findings sound equally -Soft Gross hearing intact with decreased pitch ion. s. Increased hearing high pitched sounds. (P.M.Dillo n,2007) diminished both ears non tender

Actual findings of drainage in noted. Both ears the was sounds the test. also and able to hear equally during but weber The was the words on ears. and tick both The

Interpretation

patient

able to hear

discriminat whispered Preschyusi watch

difficulty in patient was also able to hear sound vibration the test. the of in rinne

Reproductive System

Interview

-No penile The discharge -Lesions no and

patient The

patients is

verbalizes

reproductive normal.

lesions system

System Assessed

Technique

Normal Findings (P.M.Dillo n,2007)

Actual findings discharge.

Interpretation

Genitourinary System

Interview

No urination n,2007)

The

patient Not normal. folley Urinary catheter inserted drain collect from bladder. Urinary catheters are is to and urine the

difficulty in have

catheter

(P.M.Dillo inserted.

recommended as way to

manage urinary incontinence an d retention urinary in

both men and women.

Musculoskeletal system

Inspection

-No tremors

Decrease in Not normal. muscle Decrease in

System Assessed

Technique

Normal Findings -Smooth coordinate d

Actual findings strength. Difficulty

Interpretation strength and

in tone may be with Senile kyphosis most to because is aging of related TIA or

walking and associated kyphosis noted. stroke.

movement. senile

degeneration of in vertebral disc

-No tendernes s swelling -No cramps (P.M.Dillo n,2007) leg or

Assessment on Cerebral Function

Area/

Physical Normal Findings

Actual Findings

Assessment Skill Behavior -Well posture, affect. groomed, pleasant erect -When we visited the patient, facial he had already taken a bath a the assessment. He was not really well groomed but his clothing was appropriate to the setting. He was relaxed and no unusual movements behavior were or observed.

expression,

appropriate bath and prepared himself for

The facial expression of the patient was pleasant and his affect is appropriate for the situation. -Assume Senile kyphosis posture as observed.

Level consciousness (LOC)

of -Awake, alert, and oriented -Client was awake alert and to time, place and person. oriented to time, place and -Older patients may be people. When we asked him disoriented to time, but the time he took a bath he note if they reorient easily. answered 9:00 and it was confirmed by his daughter. The patient was able to identify his address and the people he is

Area/

Physical Normal Findings

Actual Findings

Assessment Skill with.

Memory

-Immediate,

recent,

and 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.

remote memory intact.

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.

Area/

Physical Normal Findings

Actual Findings

Assessment Skill

General knowledge vocabulary

-Vocabulary and and intact. general

appropriate -The client was able to state knowledge 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 responds speech logical.

process coherent,

clear, -Though process is clear. and -Coherent and comprehensible thought as observed.

appropriately, -He had good attention span.

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.

Area/

Physical Normal Findings

Actual Findings

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 language

-Speech clear, fluent, no -The

patient

was

fluent

in

and dysarthria, circumlocution.

dysphasia, speaking, words are clear, no

dysphonia, neologisms or speech defect as observed.

-Spontaneous Speech

-Communication intact: motor

skills -We had shown 3 different

Spontaneous pictures to him and we asked to speech, sound He identified the flower, the visual writing,

speech, automatic speech, identify the pictures one by one. recognition, auditory-verbal watch and the microphone. comprehension, recognition, comprehension, visual-verbal

and copying figures.

Area/

Physical Normal Findings

Actual Findings

Assessment Skill

-Motor speech

-The client was able to repeat and continue Do, re mi, fa, so, la, ti.

-Automatic Speech

-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.

-Sound recognition

With his eyes closed, he was able to easily recognize the sound of the watch.

-Auditory-Verbal comprehension

-The client was able to follow simple directions like standing, raising his hand, smiling and etc.

-Visual

-The

client

was

able

to

Area/

Physical Normal Findings

Actual Findings

Assessment Skill recognition recognize things around sight such as pen, flower, books and etc. -Visual-Verbal comprehension -He was able to read a full sentence and elaborated the sentence in a comprehensible manner. by

watch,

-Writing

-The client was able to write his full name and address.

-Copying figures

-Client was able to copy simple figures such as triangle, circle and rectangle.

Cranial Nerve Function

Cranial Nerves CN I- Olfactory

Normal Findings -CN I intact -Sense of smell intact

Actual Findings 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

Cranial Nerves

Normal Findings

Actual Findings identified the smell of coffee as something that was burnt and identified lemon as a candy. hyposmia noted. 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. -Extra ocular movement intact,

CN II-Optic

-CN II intact -Visual acuity intact

CN Oculomotor

III- -CN III intact -Extraocular intact, PERRLA

movement Pupils reactive and responsive to direct light accommodation.

and consensual.
CN IV Trochlear

CN Trigeminal

V- -CN V intact. -Jaw +5, muscle facial

The patient was able to bite down strength slowly. The right side was stronger sensations than the left side.The patient was side. 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

intact, positive corneal also able to move his jaw side by reflex.

Cranial Nerves

Normal Findings

Actual Findings facial sensations. Positive corneal reflex was also noted. The client was able to follow the the object without turning his head. -CN VI intact The client was able to identify the

CN Abducens

VI- -CN VI intact

CN VII- Facial

-CN intact -Facial symmetrical taste

movements the taste of the vinegar as sour, on 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. The client was able to hear balance 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

anterior tongue intact.

CN Acoustic

VIII- -CN VIII intact -Hearing intact and

Cranial Nerves

Normal Findings

Actual Findings 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. The client has strong, clear voice of no signs of speech disorders as

CN IX and X- -CN IX and X intact Glossopharyng eal and Vagus -Strong, clear symmetrical rise

voice, as evidenced of fluent in speaking,

uvula, able to swallow noted. and cough. Positive gag -The positive gag reflex was noted reflex. Taste on posterior by touching the posterior aspect on tongue intact. 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 CN Accessory XI- -CN XI intact and shoulders. down. -The patient was able to shrug his 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

-Muscle strength of neck shoulders against the examiners

Cranial Nerves

Normal Findings

Actual Findings against the resistance and was able to move side by side. -No atrophy of the tongue, lesions infection

CN Hypoglossal

XII- -CN XIII intact

-Full ROM of tongue, or signs of localized fasciculation.

midline, no atrophy or noted. 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 -Light touch, pain and -The client was and temperature and lower extremities.

able

to

temperatureintact upper recognize the part of the body being touched, by pointing out the site. He pointed the site easily in both The distal patient and was proximal.

alsoable to identify that the stimulus was light. The client was able to identify whether the stimulus used to

Sensory Function

Normal Findings

Actual Findings touch, was dull or sharp. We used hair pin for sharp and the ballpen for dull. and -The client was able to feel the

Deep

sensation, -Vibratory and kinesthetic extremities.

vibratory kinesthetic

sensations vibration of the tuning fork when joints. -The client was able to identify the direction of the fingers that the examiner moved.

intact upper and lower placed on the interphalangeal

Discriminatory Sensations: -Stereognosis

Stereognosis, graphestesia, two point localization, extinction intact. and -With eyes closed, the client was able to identify the object being touched umbrella. such as pen and

-Graphesthesia

-The

client

was

able

to

determine the imaginary number and written in the palm except for letter A where the patient had difficulty in identifying.

-Two discrimination

point

-The

patient

was

able

to

differentiate whether he was touched at one or two points simultaneously.

Sensory Function

Normal Findings

Actual Findings

-Point localization

With the clients eyes closed, he was able to point out and locate the site being touched.

-Sensory Extinction

-The patient was able to identify two corresponding areas touched simultaneously.

Assessing Reflexes

Deep

tendon Normal Findings -Contraction with flexion -+2 -Contraction of

Actual Findings biceps +1/4

Reflex Biceps reflex

Triceps reflex

of

triceps +1/4

with extension at elbow Brachioradialis reflex -+2 -Flexion at elbow and +1/4 supination You may of forearm. notice also

flexion of fingers.

Deep Reflex

tendon Normal Findings -+2 -Contraction quadriceps extension of knee.

Actual Findings

Patellar reflex

of +1/4 with

Achilles reflex

-+2 -Plantar flexion of foot -+2

+1/4

Superficial Reflex Abdominal Reflex

Normal Findings -Positive abdominal reflex pregnant clients. -Positive plantar reflex -Babinski normal in infants

Actual Findings -Positive abdominal reflex

-May be absent in obese or noted. Plantar Reflex -Both left and right plantar reacted to stimulus. No babinski as noted.

Glasgow Coma Scale Area Tested Eyes Open Simultaneously Open to Speech Open to painful stimuli No response Speech Oriented to person, place and time Converses but not fully oriented Converses in disorganized manner Vocalizes no recognizable words No response Motor Obeys simple commands 4 3 4 2 1 5 4 3 2 1 6 5 Best Response Points Actual finding

Does recognize local pain, but does not obey 5 commands Withdraws from painful stimuli by arm flexion Decorticate rigidity 3 Decerebeate rigidity No response 2 1 TOTAL General Survey 15 Normal 4

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.