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8/2/2019 Assessment TIA
1/24
A. Review of Systems
System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
Integumentary
System
Skin
Inspection Skin color
uneven in
areas;
increased
creases,
wrinklelines and
skin
lesions.
Some
common
lesions
include
Seborrheic
keratosis,
Senile
purpura
and
acrochord
ons.Skin
turgor is
decreased
. Skin may
be dry,
flaky &
Skin color is
uneven in
areas.
Increased
wrinkles
and creasesnoted.
Senile
purpura
noted in
some areas
of the hands
and feet.
Skin turgor
is
decreased.
Patients
skin is dry
and thin.
The patients
skin is
normal.
There are
many age-
relatedchanges in
the skin.
Other
normal
variation
are caused
by the frail
nature of
capillaries
and
decreased
collagen
support.
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
Palpation
thin.
Temperatu
re: warm
but hands
and feet
may be
cool.
Patients
skin is warm
to touch.
Hand is
cool.
Hair
HEENT
Inspection General ly
black/brow
n in color.
Gray in
color for
the older
adults.
Thin hair.
Scalp may
be dry for
older
adults.
Gray
colored
hair.
-Thin hair
.
-Scalp is
smooth and
oily no
presence of
lesions
noted.
Gray coloring
occurs with
aging.
-Hair thins
with age.
(Wi lk inson &
Van Leuven,
2007)
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
Head/Nec
k
Eyes
Inspection
Palpation
Inspection
Normocep
hali c and
symmetric.
May have
decreased
ROM.
-Absence
of masses
and
tenderness.
(Lynn B.
2009)
-Eyes are
c lear and
bright and
parallel
alignment.
-White
sclera
-in parallel
alignment
-No
Upon
inspection
head is
normocepha
lic and
symmetrical
. Patient
was able to
turn his
head onboth sides.
No
tenderness
and swollen
lymph
nodes
noted.
-Eyes are in
parallel
alignment
-No edema
on the
eyelids.
-Eyelashes
are even ly
distributed
and curved
The patients
head and
neck is
normal.
.
The patients
eyes are
normal.
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
lesions
and
edema
present,
l ids move
freely
,eyelashes
are evenly
distributed
andcurved
outward,
no
excessive
tearing
nystagmus
or lid lag
-Palpebral
conjunctiv
a is
smooth,
Minimal
blood
vessels
are
present.
Pupils are
reactive to
light. Eyes
outward.
Minimal
blood
vessels are
present.
White sclera
is visible.
-Pupi ls are
equal
reactive tolight.
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
may be
dry and
decreased
visual
acuity and
periphery
is a
normal
variation
in theolder
adults.
Nose Inspection Nost ri ls
are patent.
Decreased
sense of
smell,
elongated
nose,
increased
nasal hair.
(P.M.Dillo
n, 2007)
The
patients
nostr ils are
patent.
Decreased
sense of
smell noted.
The patients
nose is
normal.
Anosomia-
decreased
ability to
identify and
discriminate
odors occurs
with aging.
Ears Inspection -Intact
skin, no
drainage
or lesions
-Hears the
-Upon
inspection
skin is
intact wi th
no presence
The patients
Ears are
normal.
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
sound
equal ly in
both ears
-Soft and
non tender
Gross
hearing
intac t but
diminished
withdecreased
pitch
discriminat
ion.
Preschyusi
s.
Increased
difficulty in
hearing
high
pitched
sounds.
(P.M.Dillo
n,2007)
of drainage
noted. Both
ears was
able to hear
the sounds
equally
during the
weber test.
The patient
was alsoable to hear
the
whispered
words and
watch tick
on both
ears. The
patient was
also able to
hear the
sound of
vibration in
the rinne
test.
Reproductive
System
Interview -No penile
discharge
-Lesions
The patient
verbalizes
no lesions
and
The patients
reproductive
system is
normal.
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
(P.M.Dillo
n,2007)
discharge.
Genitourinary
System
Interview No
difficulty in
urination
(P.M.Dillo
n,2007)
The patient
have fol ley
catheter
inserted.
Not normal.
Urinary
catheter is
inserted to
drain and
collect urine
from the
bladder.
Urinary
catheters are
recommended
as way to
manage urinary
incontinencean
d urinary
retention in
both men and
women.
Musculoskeletal
system
Inspection -No
tremors
Decrease in
muscle
Not normal.
Decrease in
http://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.htmlhttp://health.nytimes.com/health/guides/disease/stress-incontinence/overview.html8/2/2019 Assessment TIA
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System
Assessed
Technique Normal
Findings
Actual
findings
Interpretation
-Smooth
coordinate
d
movement.
-No
tendernes
s or
swelling
-No leg
cramps
(P.M.Dillo
n,2007)
strength.
Dif ficulty in
walking and
senile
kyphosis
noted.
strength and
tone may be
associated
with TIA or
stroke.
Senile
kyphosis is
most related
to aging
because of degeneration
of in vertebral
disc
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Assessment on Cerebral Function
Area/ Physical
Assessment Skill
Normal Findings Actual Findings
Behavior -Well groomed, erect
posture, pleasant facial
expression, appropriate
affect.
-When we visited the patient,
he had already taken a bath a
bath and prepared himself for
the assessment. He was not
really well groomed but his
clothing was appropriate to the
setting. He was relaxed and no
unusual behavior or
movements were observed.
The facial expression of the
patient was pleasant and his
affect is appropriate for the
situation.
-Assume Senile kyphosis
posture as observed.
Level of
consciousness
(LOC)
-Awake, alert, and oriented
to time, place and person.
-Older patients may be
disoriented to time, but
note if they reorient easily.
-Client was awake alert and
oriented to time, place and
people. When we asked him
the time he took a bath he
answered 9:00 and it was
confirmed by his daughter. The
patient was able to identify his
address and the people he is
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Area/ Physical
Assessment Skill
Normal Findings Actual Findings
with.
Memory -Immediate, recent, and
remote memory intact.
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.
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.
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Area/ Physical
Assessment Skill
Normal Findings Actual Findings
General
knowledge and
vocabulary
-Vocabulary appropriate
and general knowledge
intact.
-The client was able to state
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 process clear,
responds appropriately,
speech coherent, and
logical.
-Though process is clear.
-He had good attention span.
-Coherent and comprehensible
thought as observed.
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.
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Area/ Physical
Assessment Skill
Normal Findings Actual Findings
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 and
language
-Speech clear, fluent, no
dysarthria, dysphasia,
dysphonia, neologisms or
circumlocution.
-The patient was fluent in
speaking, words are clear, no
speech defect as observed.
-Spontaneous
Speech
-Communication skills
intact: Spontaneous
speech, automatic speech,
motor speech, sound
recognition, auditory-verbal
comprehension, visual
recognition, visual-verbal
comprehension, writing,
and copying figures.
-We had shown 3 different
pictures to him and we asked to
identify the pictures one by one.
He identified the flower, the
watch and the microphone.
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Area/ Physical
Assessment Skill
Normal Findings Actual Findings
-Motor speech
-Automatic
Speech
-Sound
recognition
-Auditory-Verbal
comprehension
-Visual
-The client was able to repeat
and continue Do, re mi, fa, so,
la, ti.
-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.
With his eyes closed, he was
able to easily recognize the
sound of the watch.
-The client was able to follow
simple directions like standing,
raising his hand, smiling and
etc.
-The client was able to
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Area/ Physical
Assessment Skill
Normal Findings Actual Findings
recognition
-Visual-Verbal
comprehension
-Writing
-Copying figures
recognize things around by
sight such as pen, watch,
flower, books and etc.
-He was able to read a full
sentence and elaborated the
sentence in a comprehensible
manner.
-The client was able to write his
full name and address.
-Client was able to copy simple
figures such as triangle, circle
and rectangle.
Cranial Nerve Function
Cranial Nerves Normal Findings Actual Findings
CN I- Olfactory -CN I intact
-Sense of smell intact
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
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Cranial Nerves Normal Findings Actual Findings
identified the smell of coffee as
something that was burnt and
identified lemon as a candy.
hyposmia noted.CN II-Optic -CN II intact
-Visual acuity intact
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.
CN III-Oculomotor
-CN III intact-Extraocular movement
intact, PERRLA direct
and consensual.
-Extra ocular movement intact,Pupils reactive and responsive to
light accommodation.
CN IV Trochlear
CN V-
Trigeminal
-CN V intact.
-Jaw muscle strength
+5, facial sensations
intact, positive cornealreflex.
The patient was able to bite down
slowly. The right side was stronger
than the left side.The patient was
also able to move his jaw side byside. 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
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Cranial Nerves Normal Findings Actual Findings
facial sensations. Positive corneal
reflex was also noted.
CN VI-
Abducens
-CN VI intact The client was able to follow the
the object without turning his head.-CN VI intact
CN VII- Facial -CN intact
-Facial movements
symmetrical taste on
anterior tongue intact.
The client was able to identify the
the taste of the vinegar as sour,
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.
CN VIII-
Acoustic
-CN VIII intact
-Hearing and balance
intact
The client was able to hear
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
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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.
CN IX and X-
Glossopharyng
eal and Vagus
-CN IX and X intact
-Strong, clear voice,
symmetrical rise of
uvula, able to swallow
and cough. Positive gag
reflex. Taste on posterior
tongue intact.
The client has strong, clear voice
as evidenced of fluent in speaking,
no signs of speech disorders as
noted.
-The positive gag reflex was noted
by touching the posterior aspect on
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
down.
CN XI-
Accessory
-CN XI intact
-Muscle strength of neck
and shoulders.
-The patient was able to shrug his
shoulders against the examiners
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
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Cranial Nerves Normal Findings Actual Findings
against the resistance and was
able to move side by side.
CN XII-
Hypoglossal
-CN XIII intact
-Full ROM of tongue,midline, no atrophy or
fasciculation.
-No atrophy of the tongue, lesions
or signs of localized infectionnoted. 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
and temperature
-Light touch, pain and
temperatureintact upper
and lower extremities.
-The client was able to
recognize the part of the body
being touched, by pointing out
the site. He pointed the site
easily in both distal and
proximal. The patient was
alsoable to identify that the
stimulus was light.
The client was able to identify
whether the stimulus used to
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Sensory Function Normal Findings Actual Findings
touch, was dull or sharp. We
used hair pin for sharp and the
ballpen for dull.
Deep sensation,vibratory and
kinesthetic
-Vibratory andkinesthetic sensations
intact upper and lower
extremities.
-The client was able to feel thevibration of the tuning fork when
placed on the interphalangeal
joints.
-The client was able to identify
the direction of the fingers that
the examiner moved.
Discriminatory
Sensations:
-Stereognosis
-Graphesthesia
-Two point
discrimination
Stereognosis,
graphestesia, two point
localization, and
extinction intact. -With eyes closed, the client was
able to identify the object being
touched such as pen and
umbrella.
-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.
-The patient was able to
differentiate whether he was
touched at one or two points
simultaneously.
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Sensory Function Normal Findings Actual Findings
-Point localization
-Sensory
Extinction
With the clients eyes closed, he
was able to point out and locate
the site being touched.
-The patient was able to identify
two corresponding areas
touched simultaneously.
Assessing Reflexes
Deep tendon
Reflex
Normal Findings Actual Findings
Biceps reflex -Contraction of biceps
with flexion
-+2
+1/4
Triceps reflex -Contraction of triceps
with extension at elbow
-+2
+1/4
Brachioradialis
reflex
-Flexion at elbow and
supination of forearm.
You may also notice
flexion of fingers.
+1/4
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Deep tendon
Reflex
Normal Findings Actual Findings
-+2
Patellar reflex -Contraction of
quadriceps withextension of knee.
-+2
+1/4
Achilles reflex -Plantar flexion of foot
-+2
+1/4
Superficial Reflex Normal Findings Actual Findings
Abdominal Reflex -Positive abdominal reflex
-May be absent in obese or
pregnant clients.
-Positive abdominal reflex
noted.
Plantar Reflex -Positive plantar reflex
-Babinski normal in infants
-Both left and right plantar
reacted to stimulus. No
babinski as noted.
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Glasgow Coma Scale
Area
Tested
Best Response Points Actual
finding
Eyes Open Simultaneously
Open to Speech
Open to painful stimuli
No response
4
3
2
1
4
Speech Oriented to person, place and time
Converses but not fully oriented
Converses in disorganized manner
Vocalizes no recognizable words
No response
5
4
3
2
1
5
Motor Obeys simple commands
Does recognize local pain, but does not obey
commands
Withdraws from painful stimuli by arm flexion
Decorticate rigidity
Decerebeate rigidity
No response
6
5
4
3
2
1
6
TOTAL 15
Normal
General Survey
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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.