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Summary Of A Reflective Account

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I assessed 71 years old female, Ms. Smith (fake name), who appeared in good physical health. She was alert and oriented because she was able to tell me the correct date and place. She did not seem to be in any distress. Eyes were symmetrical, sclera was white, and pupils were equal, round, reactive to light, and accommodating, and extraocular movements were intact. No hearing deficit was noted because Ms. Smith was able to repeat the words that I whispered into her each ear. I did not note any breathing difficulties as she was able to breathe through both nares equally, lungs were clear bilaterally upon auscultation, and she denied shortness of breath. No swelling or tenderness was noted on palpitation of lymph nodes. Ms. Smith denied heart pain or palpitation, and heart beats were regular upon auscultation. Extremities were symmetrical bilaterally, and muscle strength was strong upon assessment. …show more content…

Smith scored 15 on balance and 12 on gait assessment which is 27 out of 28, making her fall risk low. She set on the couch without any support but used her hands to stand up. She did not stagger while standing with both feet together and eyes shut for 10 seconds, as well as maintained balance upon nudging. Ms. Smith made a full 360-degree turn without stopping. She had steady gait during walking with appropriate length between both feet, picked up and touched the ground with each foot, and was able to turn back without staggering. She also did not have loose rugs in the house as well as medications stored in the high cabinet in the

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