Bacalla, Khesler Bernie N.

BSN-3D

Biographical Data

D.H, a 58-year-old male born on January 22, 1957. He is 5 feet and 11 inches weighing
181 pounds. He is overweight.

A. Cognitive status

Upon assessment, the patient’s behavior is awake and alert. Also he is cooperative and
responding well. As observed the patient has appropriate motor activity. The patient is well
oriented in the time, date, person and the situation where he’s in. there are no problem
observed in his memory and concentration since he was able to answer all the question given
by the health practitioner. His mood and effect is all appropriate for the situation. There are no
observe difficulties in language and communication. Intellectual judgement and insight were all
access and then is no problem noted.

B. RLS & GCS

RLS
SCORE: 1= alert
Since when the examiner enters the room, the patient quickly responded to the
knock of the examiner.

GCS:

SCORE: 15

EYE OPENING- 4 SPONTANEOUS

Since the patient is alert and awake. He was able to concentrate to the
questions being asked without being drowsy.

VERBAL RESPONSE-5 ORIENTED

Since the patient was able to answer the question correctly without any
hesitation.

MOTOR RESPONSE-6 OBEYING

Since the patient was able to do actions when being asked. For example

Shrugging shoulders, smiling, frown, standing and etc..

C. CANIAL NERVE

CRANIAL NERVE METHOD OF INDICATIONS

ASSESSMENT
I. OLFACTORY not assessed
II. OPTIC  Let client stand 20  Visual acuity is
feet from the 20/25
Snellen’s chart  Peripheral vision is
 Confrontation test: intact
a card is place  No vision loss
over the one eye noted
having the patient
looking directly at
the examiner eye
or nose
and testing each
quadrant in the
patient's visual
field by having
them count the
number of fingers
that the examiner
are showing
III. OCULOMOTOR,  The examiner  Conjugate
IV-TROCHLEAR, instructs the movement of the
VI. ABDUCENS patient to follow eyes together in
the pen in the six six cardinal
cardinal position of position of the
gaze keeping the gaze
head straight
 Accommodation  Good
test. The examiner accommodation
instructs the
patient to follow
the pen towards
 his nose  PERRLA ( pupil
 Pupillary are equally round
constriction. The reactive to light
examiner shine a and
light in the accommodation.
patient’s eyes to
see if both of them
respond to light by
constricting.
V. TRIGEMINAL  The examiner  The muscles are
instructs the nice, tight and they
patient to smile, are relaxed
frown and show
his teeth plate
 The examiner ask  The patient was
the patient to close able to feel the
his eyes to test his cotton ball on his
sensation with face
cotton ball.
VII. FACIAL  The examiner asks  The patient shows
the patient to lift symmetry of the
his eyebrows up face; damage
and down. Then cranial nerve VII
smile, frown and means it is bells
close his eyes real palsy or stroke
tight.
VIII.  The examiner  The acoustic
VESTIBULOCOCHLEAR whisper something nerve is intact. He
in the patients ear was able to repeat
and the patient the words properly
needs to repeat it ;” green wall” and “
the cub are going
to win”
IX.  The examiner ask  The uvula goes up
GLOSSOPHARYNGEAL, the patient to open and the soft palate
 X.VAGUS his mouth “say ah” up therefore the
cranial nerve
number 9 and 10
are intact
XI. ACCESSORY  The examiner ask  The cranial nerve
the patient to turn number 11 is
against her hand intact;
and shrug up abnormalities:
against her hand drooping of a
shoulder, muscle
atrophy, weak
shoulder shrug.
XII.HYPOGLOSSAL  The examiner ask  The tongue is in
the patient to stick the midline
his tongue out  Abnormalities are
deviation of
tongue to weak
side, atrophy,
fasciculation and
slurred speech

J. BALANCE AND COORDINATION

a. Fingers to fingers test

The examiner tests the coordination of the patient by instructing the patient to do
the fingers to fingers test as quickly as he can. The patient was able to touch his
finger quickly without a problem.

b. Finger to nose
The examiner asks the patient to touch his nose and touch the examiner’s finger
as quickly as he can. Since the patient was able to do it simultaneously, there are
no problems regarding with that.
c. Heel down opposite shin
 While the patient is still sitting, the examiner instructs the patient to take his shin
and just run it down to the opposite shin. The patient was able to do it without
any hesitation.

d. Romberg’s test
The patient was instructed to put his feet together, put his hands at his side,
stand straight and close his eyes. the examiner would count 20 seconds and the
patient should maintain the standing straight and still without falling. The patient
was able to do the test without falling.
e. Walking gait
The patient was instructed to walk a couple of steps forward to that nearby outlet.
The patient was able to walk properly.
f. Heel to toe
The patient was instructed to comeback with heel to toe walk. The patient was
successfully walk back without any problem therefore the balance and
coordination is intact.