| Appearance: | He was too comfortable. HR 110, BP 95/50, RR 20, Sat 98%, Temp 37C. He would communicate by nodding. |
| HEENT: | Drooling, but no foreign body seen on direct visualization. |
| Lungs: | Clear bilaterally with no stridor. |
| Heart: | Regular without murmurs. |
| Abdomen: | Soft and non tender. |
| Extremities: | FROM, no signs of trauma. |
| Neuro: | Cranial nerves were grossly intact. Motor was 5/5 in all extremities. Reflexes were 2+ bilaterally and muscle tone was normal. His gait was unsteady; he would stumble to the right. |