Physical assessment

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Documentation of neurologic examination

Thelma H. Walker

Rasmussen College

COURSE#: NUR2180 Physical Assessment

Professor Casey Kelly

November 10, 2020

Subjective

Mr. Gradner, a 56-year-old Alaskan man, The Patient past medical history: Hypertension, smoking, and mild baseline of dementia. The patient is allergic to Aspirin. The patient has been admitted to acute care neurologic until the emergency department (ED) following a stroke. When the patient arrived at the ED last night, he could not provide a detailed past medical history but a patient that had been present saver(10/10), throbbing headache that had been present for “a few hours.” The patient said the headache was constant and located in the front of his head. The patient said he was unable to distinguish anything that made his headache better or worse.

Objective

Upon examination, vitals obtained: Oral Temp 36.8 C, HR 88 BPM, RR 22, and BP 168/92 mm Hg within the expected values. The patent Cranial Nerve was not tested. The Cranial Nerve II (optic Nerve)- The patient could read color and numbers using the Snellen chart. Visual Field Peripheral vision was intact. NvereIII- Pupils were equally round and reactive to light, and accommodation was excellent. Cranial III, IV, VI -pupils were reactive to light was intact, the extraocular movements no ptosis. Cranial Nerve V- The patient felt light touch to the Face. The patient could clinch the jaw with no exaggeration response—facial sensation equal to the pinprick in all three bilaterally. Cranial Nerve VII _ the patient, was able to raise eyebrows, smile, and puff out cheeks. Teeth were symmetrical. The patient could make various expressions without any problem. The Face was also symmetric with normal eye closure and smile. Cranial Nerve VIII- Fingers rub together in one side of the patient ear while whispering in the patient other ears while they sounded it out loud. Cranial Nerve IX and X uvula are mid-line while patient ‘’ah’’ to test patient gag. Cranial Nerve VII-‘’KAKA’’ and “ MAMA’’ said patient to test palpate. Cranial Nerve XI patient was able to shrug his shoulders, and he was able to turn his head from to said. Cranial Nerve XII- on the deviation to the tongue. The patient was required to stick his tongue straight out.

Risk Factors

The patient is a very healthy male but at first for anxiety due to stress overload from working too many hours. Too much energy drinks consumption, lack of sleep, and poor diet put the patient at risk for seizures.