Silchenstedt Case Study

General / Mental Status General appearance. Mr. Silchenstedt presented himself in the examination room appearing well-groomed with clean clothes that is appropriate to the situation. His clothes do not appear soiled and he does not present with foul body odor. Moreover, the patient maintains appropriate eye contact and presents with an erect posture with no involuntary movements, unilateral weakness, or tics. Mood and affect. Mr. Silchenstedt is pleasant and cooperative. His facial expression and body language are congruent with the content of his speech. He does not present with a lack or an over exaggeration of facial expression and body language. Level of consciousness. Mr. Silchenstedt is alert and oriented times four, to person (self),
The light in the consensual side (second eye) constricted equally to the direct side (the first eye) as the light enters the pupil of the second eye. Both reflexes were tested and constriction was noted to both consensual sides after both of the direct sides constricted from the light. Corneal light reflex. This exam also checks the sensory function of cranial nerve V (Trigeminal). Upon using the penlight, the light reflected symmetrically from both eyes with no evidence of involuntary movements in both eyes. Cover-uncover. Absence of strabismus noted on both eyes that were tested (covered eye). EOM/Six cardinal fields of gaze. This exam also checks the functions of cranial nerves III (Oculomotor), IV (Trochlear) and VI (Abducens). Patient performed the exam with no signs of nystagmus or involuntary movements in both eyes. Ophthalmoscope examination. Positive red reflexes were noted to both eyes. The fundus in both eyes appear light yellow, with no evidence of hemorrhage and Drusen bodies. Both the optic discs have well-defined or sharp margins and are round. The macula is a disc and a half away from the optic disc in the right eye, and is two discs away from the optic disc in the left