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  • Health Assessment: Focus on Abnormal Findings

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    Danna Tan
    44 vizualizări2 pagini
    The client presented with abnormal findings on neurological and musculoskeletal examination. Specifically, the client had weakness and decreased muscle strength in the left leg, with dragging of the left foot. Urination also required straining and showed signs of hesitancy. The remainder of the examination was normal.

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    Review of Systems

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    The client presented with abnormal findings on neurological and musculoskeletal examination. Specifically, the client had weakness and decreased muscle strength in the left leg, with dragging of the left foot. Urination also required straining and showed signs of hesitancy. The remainder of the examination was normal.

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    Attribution Non-Commercial (BY-NC)
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    44 vizualizări2 pagini

    Health Assessment: Focus on Abnormal Findings

    Încărcat de

    Danna Tan
    The client presented with abnormal findings on neurological and musculoskeletal examination. Specifically, the client had weakness and decreased muscle strength in the left leg, with dragging of the left foot. Urination also required straining and showed signs of hesitancy. The remainder of the examination was normal.

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    Attribution Non-Commercial (BY-NC)
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    din 2

    Focus Health Assessment:

    Systems Normal Abnormal


    Integumentary Skin fair noted moles and age spots no noted
    wounds. Nail beds clean. No pressure ulcers
    noted. skin turgor returns immediately when
    pinched
    Head Normocephalic head, hair long and clean no
    presence of lice or dandruff equally distributed.
    Anicteric sclerae pink conjunctive, pupil 3mm
    equal reactive to light 6 cardinal gazes intact, no
    facial asymmetry, gross hearing intact able to
    differentiate taste and smell uvula in midline
    tongue in midline
    Respiratory Clear breath sound no difficulty in breathing no
    rales or wheezing noted. Equal chest expansion
    no gross deformities
    Cardiovascular Distinct s1 s2 palpable pulses regular in rhythm
    Musculo skeletal Upper extremities graded 5/5 reflexes +2 able to Noted to be dragging left foot,
    walk with assistance muscle strength in left leg is 3/5
    while on the right 4/5. Able to feel
    light touches but not all able to feel
    sharp and dull but makes mistakes
    sometimes
    Digestive No gross deformities, hypoactive bowel sounds Constipated unable to defecate for
    3 days
    Urinary No pain during urination Need straining for urination
    hesitancy
    Plexus and Origin Nerves Assessment
    Cervical (C1-C4) Phrenic Client able to move from side to side and up and down

    Brachial( C5-T1) Axillary Able to raise hands and elbows, able to shrug

    Radial Hands and arms able to extend muscle strength graded


    5/5 both extremities
    Musculo cutaneous Hands and arms able to flex muscle strength graded
    5/5 both extremities
    Ulnar Able to grasp object and flex fingers without difficulty
    Median Able to grasp object and flex fingers without difficulty
    Not Applicable(T2-T8) Intercostal Able to breath w/o difficulty, good shrug, able to raise
    nerves(Thorax) hand w/o difficulty muscles in back are strong,
    abdominal muscles able to move
    Lumbosacral(L1-S4) Obturator Thighs able to push inside able to adduct graded4/5 on
    right leg 3/5 on left
    Femoral Thighs able to extend outward graded 4/5 on both
    extremities
    Sciatic tibial Able to dorsi flex of feet graded 4/5 on right leg 3/5 on
    left able to push leg muscle up
    Common Fibular Able to plantar flex graded 4/5 on right leg 3/5 on left
    Able to push lower leg down
    Numb Name Assessment
    er
    1 Olfactory Able to differentiate vinegar from coffee scent
    2 Optic Pupil 3mm Equal Reactive to light
    3 Oculomotor Able to close upper eyelid and able to follow 6 cardinal gazes, pupils able to
    constrict when light present
    4 Trochlear Able to close upper eyelid and able to follow 6 cardinal gazes
    5 Trigeminal Able to chew food without difficulty
    6 Abducent Able to close upper eyelid and able to follow 6 cardinal gazes
    7 Facial No facial asymmetry. Can differentiate salty to sweet taste, is able to cry and no
    problem in salivary glands
    8 Vestibulocochl Air conduction greater than bone conduction, intact gross hearing
    ear
    9 Glossopharyn Can swallow food without difficulty uvula in midline, Can differentiate salty to
    geal sweet taste
    10 Vagus Can swallow food without difficulty uvula in midline
    11 Accessory Able to turn head. Good shrug
    12 Hypoglossal Tongue in midline, able to move tongue

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