PHYSICAL ASSESSMENT: Date of Assessment: Jan. 25, 2010 Time performed: 10:30am Height = 167.64 cm Weight = 65 g !

"W = 61 g Place of Assessment: ##W 4th $%oor, "ed 406 " General Appearance: &'amine %(ing on )ed, afe)ri%e, con*cio+*, re*pon*i,e, coherent, -ith !. $ of 1 #/00 1 %iter at 60 cc1min inf+*ing -e%% at %eft arm -ith the fo%%o-ing .ita% 0ign*: "#= 110160 mmHg, #2= 31 )pm, 22= 22 cpm T=36.5 41 a'i%%a. 05!/: -arm to to+ch, -ith good t+rgor, no %e*ion*, negati,e *triae on a)domina% * in, %ight )ro-n in comp%e'ion, 678 9a+ndice H&:; < H:!2: normocepha%ic, -ith no * +%% deformitie*, no f%a e*, no %ice, no dandr+ff, no tenderne** +pon pa%pation, )%ac and gra(ing co%ored hair, e=+a%%( di*tri)+ted, *(mmetric and *+pp%e, no %e*ion*, no nod+%e*, no ma**e* noted &>&0: *(mmetrica% in *hape and *i?e, no a)norma% di*charge* noted, 678 #&22@:, 678 cardina% ga?e, e(e)ro-* are )%ac in co%or, *hort and e,en%( p%aced, *(mmetrica% e(e%id opening, *(mmetrica% )%in ing, in,o%+ntar( )%in , (e%%o-i*h *c%erae, pa%e pa%pe)ra% con9+ncti,ae, cornea i* tran*parent, iri* i* e=+a%%( ro+nd and +niform in co%or, p+pi%* reacti,e to %ight )( *%ight con*triction, can *ee *t+dentA* namep%ate at 2 ft. di*tance, -a* a)%e to identif( co%or* *+ch a*: )%ac , )%+e, green and red, doe*nAt +*e e(eg%a**e* &:20: no ,i*i)%e cer+men *een on %eft < right ear*, no tenderne**, no a+ra% di*charge*, o+ter pinna in %ine -ith the inner canth+* of the e(e, )oth ear* *(mmetrica% BCDTH: no %e*ion* noted, 678Eag 2ef%e', no tenderne**, pin ora% m+co*a, ha%ito*i*, (e%%o-i*h teeth, incomp%ete *et of teeth: 15 +pper and 12 %o-er, denta% carrie*, tong+e at the mid%ine, +,+%a at mid%ine, no ton*i%%ophar(ngea% conge*tion /&45: *(mmetric -ith the head centered, f+%% 2CB, *mooth and contro%%ed, trachea at mid%ine, th(roid g%and pa%pa)%e -hen c%ient *-a%%o-*, *mooth, firm, non tender and -itho+t nod+%e* and )r+it*, %(mph node* non pa%pa)%e 4H&0T < @D/E0: e=+a% che*t e'pan*ion, no %e*ion*, no tenderne**, no *-e%%ing, 22: 22 cpm, +*e of acce**or( m+*c%e +pon )reathing H&:2T :/; #&2!#H&2:@ .:04D@:TD2&: di*tinct *1 and *2 heart *o+nd* +pon a+*c+%tation, no m+rm+r, no che*t pain, heart rate at 31 )pm -ith reg+%ar rh(thm , 73 pa%pa)%e periphera% p+%*e* on )oth +pper and %o-er e'tremitie*, no thri%%* +pon pa%pation, no )r+it* +pon a+*c+%tation #D@0& 0T2&/ETH 0F :"0&/T 71F -ea , thread(, diffic+%t to pa%pate, o)%iterated -ith pre**+re 72, dimini*hed p+%*e, canAt )e o)%iterated 73F ea*( to pa%pate, f+%% p+%*e, canAt )e o)%iterated 74 *trong )o+nding p+%*e /:!@0: pa%e nai% )ed*, dirt( and %ong finger nai%*, nai% c%+))ing, nai% p%ate firm%( attached to the nai% )ed

:";CB&/: di*tended a)domen, :E = 3G.7in, *triae not note*, +m)i%ic+* at mid%ine, rece**ed and -itho+t )+%ging, no ma**e* pa%pated, no organomega%(, 678 *hifting d+%%ne**, 678 f%+id -a,e te*t 2&4TDB: intact, no ra*he*, no hemorrhoid*, no a)norma% di*charge*, no itchine** ":45 :/; &HT2&B!T!&0: 73 periphera% p+%*e*, -ith 415 2CB %o-er e'tremitie*, e=+a% m+*c%e *trength 6)oth +pper e'tremitie* and )oth of %o-er e'tremitie*8, pre*ence of non pitting edema on )oth %o-er e'tremitie* no %e*ion, no *car, no tenderne**, no deformitie*, can fee% *en*ation* at )oth %o-er and +pper e'tremitie* 6can fee% pinch and tip of pen8, no thri%%* +pon pa%pation, no )r+it* +pon a+*c+%tation, 6F8 a*teri'i*

MUSCLE STRENGTH 2 415 315 @ 415 31 5

E2:;!/E 04:@&: 5F f+%% 2CB again*t gra,it(, f+%% re*i*tance 4F f+%% 2CB again*t gra,it(, *ome re*i*tance 3F f+%% 2CB -ith gra,it( 2F f+%% 2CB -ith gra,it( e%iminated, pa**i,e motion 1F *%ight reaction 0F no reaction EDT :/; 2&#2C;D4T!.&: gro**%( ma%e, circ+mci*ed, no a)norma% di*charge*, 678 *-e%%ing on *crot+m, no %e*ion*, , no itching, no ra*he*, no pain +pon +rination, 6F8 5idne( p+nch *ign NEUROLOGIC ASSESSMENT I Mental Assessment a-a e, *%ight incoherence to time, p%ace, per*on, and a)%e to fo%%o- in*tr+ction* proper%(, good e(e contact, *pea * in moderate tone, *hort term memor( intact 6a)%e to reca%% on*et of *(mptom*8, %ong term memor( intact 6a)%e to reca%% name, addre**, and )irthdate8, -ith a E40 of 15 II Cere!ellar Assessment 678 finger to finger te*t 678 finger to no*e te*t !n,o%+ntar( mo,ement* not noted 6F8 2om)ergA* te*t III Sensor" Assessment 678 *tereogno*i* 6 e(* identified -hi%e e(e* are c%o*ed8 678 graphe*the*ia 6a)%e to identif( %etter C at the )ac 8 678 2F point di*crimination 6a)%e to identif( *harp from d+%%8

678 ine*the*ia 6a)%e to identif( the direction to -hich the finger -a* pointing8 CRANIAL NER#ES: !. !!. !!!. !.. .. .!. .!!. .!!!. !H. H. H!. C%factor( 6*en*or(8: can di*ting+i*h the *cent of orange and coffee Cptic 6*en*or(8: a)%e to read *t+dentA* namep%ate at a di*tance of 2 feet Cc+%omotor 6motor8: e=+a% e(e mo,ement Troch%ear 6motor8: 678 #&22@:I -ith congr+ent e(e mo,ement 6)a*ed on o)*er,ation8 Trigemina% 6*en*or(8: 678 )%in ref%e', can open and c%o*e mo+th, can fee% to+ch on face :)d+cen* 6motor8: 678 #&22@:I -ith congr+ent e(e mo,ement 6)a*ed on o)*er,ation8 $acia% 6*en*or(8: can fee% %ight to+ch on face 6motor8: a)%e to *mi%e and fro-n :co+*tic 6*en*or(8: a)%e to hear -hi*pered -ord* at 2 feet di*tance E%o**ophar(ngea% and .ag+* 6motor8: can *-a%%o6*en*or(8: 678 gag ref%e' 0pina% :cce**or( 6motor8: a)%e to t+rn head to *ide, a)%e to *hr+g *ho+%der* again*t re*i*tant H(pog%o**a% 6motor8: can mo,e tong+e from *ide to *ide DEEP TENDON RE$LE%ES E2:;!/ E: 72 72 72 72 72

"rachioradia%i* "icep* Tricep* #ate%%ar :chi%%e*

04:@&: 0 J /o ref%e' 71 J Binima% :cti,it( 72 J /orma% acti,it( re*pon*e* 73F Bore acti,e than norma% 74F Ba'ima% acti,it( 6h(peracti,e