GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
NEURO
MENTAL STATUS: AAOx3, memory intact, fund of knowledge appropriate
LANG/SPEECH: Naming and repetition intact, fluent, follows 3-step commands
CRANIAL NERVES:
II: Pupils equal and reactive, no RAPD, no VF deficits, normal fundus
III, IV, VI: EOM intact, no gaze preference or deviation, no nystagmus.
V: normal sensation in V1, V2, and V3 segments bilaterally
VII: no asymmetry, no nasolabial fold flattening
VIII: normal hearing to speech
IX, X: normal palatal elevation, no uvular deviation
XI: 5/5 head turn and 5/5 shoulder shrug bilaterally
XII: midline tongue protrusion
MOTOR:
5/5 muscle power in Rt shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, finger abductors/adductors. 5/5 in Rt hipflexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.
5/5 muscle power in Lt shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, finger abductors/adductors. 5/5 in Lt hipflexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.
REFLEXES: 2/4 throughout, bilateral flexor plantar response, no Hoffman's, no clonus
SENSORY:
Normal to touch, pinprick, vibration, temp all limbs
No hemineglect, no extinction to double sided stimulation (visual & tactile)
Romberg absent
COORD: Normal finger to nose and heel to shin, no tremor, no dysmetria
STATION: normal stance, no truncal ataxia
GAIT: Normal; patient able to tip-toe, heel-walk.
GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
NEURO:
Mental Status: Alert and oriented x3. Language is fluent with good comprehension.
Cranial Nerve: Pupils are equal, round, and reactive to light. Visual fields are intact to confrontation. Normal fundi. Ocular movements are intact. Face is symmetric at rest and with activation with intact sensation throughout. Hearing intact to finger rub bilaterally. Muscles of tongue and palate activate symmetrically. No dysarthria. Strength is full in sternocleidomastoid and trapezius bilaterally.
Motor: Muscle bulk and tone are normal. Strength is 5/5 in all four extremities both proximally and distally. Intact fine motor movements bilaterally. There is no pronator drift or satelliting on arm roll.
Sensory: Sensation is intact to light touch, pinprick, vibration, and proprioception throughout. Romberg is negative.
Reflexes: 2+ and symmetric at the biceps, triceps, brachioradialis, patella, and Achilles bilaterally. Plantar response is flexor bilaterally.
Coordination: No dysmetria on finger-nose-finger or heel-knee-shin. Normal rapid alternating movements. Fast finger tapping with normal amplitude and speed.
Gait: Narrow based with normal stride length and good arm swing bilaterally. Able to walk on heels, toes, and in tandem.
GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of distress, on room air
ABD: Soft, NTTP
NEURO:
GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
NEURO:
| Deltoid | Biceps | Triceps | Wrist ext | Finger abd | Hip flex | Hip ext | Knee flex | Knee ext | Ankle flex | Ankle ext | |
| R | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| L | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| Biceps | Brachio | Triceps | Knee | Ankle | Hoffman | Crossed adductor | Plantar | |
| R | 2 | 2 | 2 | 2 | 2 | - | - | down |
| L | 2 | 2 | 2 | 2 | 2 | - | - | down |
Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes.
Coordination:
Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is absent.
Gait/Stance:
Posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes.
GEN: NAD
CVS: RRR,
CHEST: No signs of resp distress
ABD: Soft, NTTP
NEURO:
HC:
AF: Soft and flat
Mental status: Alert, awake
CN: Pupils b/l equal and reactive, EOMI, VF seem intact, face symmetrical, facial sensation intact b/l, head turn seems normal.
Motor: Moving all 4 extremities equally
Sensory: Intact to tickle in all 4 extremities and face b/l
Reflexes: +ve b/l palmar and plantar grasp, +rooting, +suck, + moro's, b/l babinksi present
GEN: NAD, pleasant, playing, running around in room.
CVS: RRR,
CHEST: No signs of resp distress
ABD: Soft, NTTP
NEURO:
Mental status: Alert, awake, oriented to mom, dad, playing
Language: Speaks in one or two words.
CN: Pupils b/l equal and reactive, EOMI, VF seem intact, face symmetrical, facial sensation intact, haed turn seems normal.
Motor: Moving all 4 extremities equally
Sensory: Intact to touch in all 4 extremities and face b/l
Reflexes: 2/4 throughout, no Hoffman's, no clonus, bilateral flexor planter responses
Coord/Rhombergs/Stance/Gait: walking and running in room, normal gait, no ataxia.
--> Parkinsonian gait & bilateral rigidity, the rest of motor/sensory exam is normal - UPDRS motor part is added to describe parkinsonian features.
GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
NEURO:
Mental Status: The patient is alert, attentive, and oriented to time, place and person.
Speech: clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes.
Cranial nerves:
CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: EOMI, no nystagmus, no ptosis
CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally.
CN VII: Face is symmetric with normal eye closure and smile.
CN VII: Hearing is normal to rubbing fingers
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact
CN XII: Tongue is midline with normal movements and no atrophy.
Motor: There is no pronator drift of out-stretched arms. Muscle bulk is normal. Strength is 5/5 throughout. Tone is increased (rigidity) in both upper and lower extremities and around the neck.
Deltoid Biceps Triceps Wrist ext Finger abd Hip flex Hip ext Knee flex Knee ext Ankle flex Ankle ext
Reflexes: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor.
Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes.
Coordination: Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg test is negative.
Gait/Stance: Stooped posture, short steppage gait with decreased arm associative movements. Turns in block but no gait freezing.
UPDRS: (each item scored from 0 to 4, 0 is normal) -Speech
-Facial expression
-Resting tremors
-Postural/action tremors
-Rigidity
-Finger taps
-Hand movements
-Rapid alternating movements
-Leg agility
-Arising from a chair
-Posture
-Gait
-Postural stability
-Bradykinesia
TOTAL SCORE:
Gen: Laying in bed, no apparent distress
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
Neuro:
Mental status:
Psychomotor activity: normal.
Affect: normal.
Judgement: fair.
Insight: fair.
Orientation: Orineted to time place and person.
Attention: normal attention span, can spell WORLD backwords, could do serial 7 subtractions.
Memory: impaired delayed recall, could remember only 1 of 3 objects in 5 minutes - longterm memory appears normal.
Excutive functions: could replicate a cube, draw a clock.
Abstraction: Could relate different objects (fruits, tools).
Language: fluent.
CNs: Pupils b/l equal 3mm, reactive, EOMI seems intact, face symmetric, tongue midline.
Motor: Limited due to patient not following commands but moving all 4 extremities equally and spontaneously. Roughly 4+/5 throughout
Sensory: Intact to pin prick in all 4 extremities and face bilaterally.
Reflexes: 2/4 throughout, bilateral flexor plantar response, no Hoffman's, no clonus
Coordination no observed nystagmus or appendicular ataxia on spontaneous movements
Gen: Laying in bed, no distress
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
Neuro:
MS: awake, alerts to name but not attentive , not following commands
Language: says few sentences - requires repeated stimulation to follow simple commands
CNs: Pupils b/l equal 3mm, reactive, EOMI seems intact, face symmetric, tongue midline.
Motor: Limited due to patient not following commands but moving all 4 extremities equally and spontaneously. Roughly 4+/5 throughout
Sensory: reacts to pain in all extremities
Reflexes: 2/4 throughout, bilateral flexor plantar response, no Hoffman's, no clonus
Coordination no observed nystagmus or appendicular ataxia on spontaneous movements
Gen: Laying in bed, eyes closed, not following commands consistently
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress
ABD: Soft, NTTP
Neuro:
MS: sleepy, awakens to repeated stimuli, not attentive, sometime tracks but not following commands.
Language: Not following simple commands, occasionally saying yes to random questions.
CNs: Pupils b/l equal 3mm, reactive, EOMI seems intact, face symmetric, tongue midline. Rest of cranial nerves are intact.
Motor: Limited due to patient not following commands but withdraws to pain in all extrenities equally.
Sensory: reacts to pain in all extremities
Reflexes: 2/4 throughout, bilateral flexor plantar response, no Hoffman's, no clonus
Coordination: no evident nystagmus or ataxia
Gait: deferred due to mental status
Stuperus difficutl to arouse – withdraws
Gen: Laying in bed, eyes closed, not following commands
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress
ABD: Soft, NTTP
Neuro:
MS: stuperous, opens her eyes only to pain, not attentive, not tracking, not following commands
Language: Not following simple commands, non-verbal.
CNs: Pupils b/l equal 3mm, reactive, cephalo-ocular reflex intact, face symmetric, tongue midline. Rest of cranial nerves are intact.
Motor: Limited due to patient not following commands but withdraws to pain in all extremities.
Sensory: reacts to pain in all extremities
Reflexes: 2/4 throughout, bilateral flexor plantars
Coordination: deferred - unresponsive
Gait: deferred due to mental status
Gen: Laying in bed, eyes closed, no spontaneous movements
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress
ABD: Soft, NTTP
Neuro:
MS: no response to verbal or painful stimuli
Language: intubated - comatose
CNs: Pupils b/l equal 2mm with sluggish reaction, cephalo-ocular reflex intact, face symmetric, cough and gag present, rest of cranial nerves exam is limited by mental status.
Motor: no response to painful stimulation 0/5 throughout
Sensory: no response to pain
Reflexes: no reflexes could be elicited
Coordination: not assessed, patient is unresponsive
GAIT: deferred due to mental status
General: lying down in bed, no apparent distress - sedated - no spontaneous movements
CVS: RRR, no carotid bruit.
Lungs: on mechanical ventillation, clear breath sounds
Abdomen: Soft, NTTP
Extremities: no edema or cyanosis
Neuro:
MENTAL STATUS: sedated on propofol
LANG/SPEECH: non-verbal (sedated)
CRANIAL NERVES: Pupils are equal and reactive, face symmetric - poor cough and gag to suctioning, rest of cranial nerves were deferred due to sedation.
MOTOR: no spontaneous movements - no withdrawal to pain on either side (sedated)
REFLEXES: hyporeflexic bilaterally
SENSORY: no reaction to pain in both sides
COORD: deferred - sedated
GAIT: deferred - sedated
General: no apparent distress
CVS: RRR, no carotid bruit
Chest: No signs of resp distress, clear breath sounds
Abdomen: Soft, NTTP
Extremities: no edema or cyanosis
Neuro:
MENTAL STATUS: awake, alert, globally aphasic (can't assess fund of knowledge).
LANG/SPEECH: global aphasia
CRANIAL NERVES:
II: Pupils equal and reactive, no RAPD, Rt hemianopia
III, IV, VI: EOM intact, right gaze preference
VII: Rt facial weakness
VIII: normal hearing to speech
Rest of cranial nerves unremarkable
MOTOR:
Withdraws Rt UE and LE to pain but no spontaneous movement
5/5 in Lt upper and lower extremities
REFLEXES: 2/4 throughout, Rt extensor plantar response
SENSORY: reacts to pain in all limbs
Gait: deferred due to weakness
MENTAL STATUS: AAOx3
LANG/SPEECH: dysarthria with intact naming and repetition - follows commands appropriately
CRANIAL NERVES:
II: Pupils equal and reactive, no RAPD, Lt hemianopia
III, IV, VI: EOM intact, no gaze preference or deviation, no nystagmus.
V: normal
VII: Lt facial weakness
VIII: normal hearing to speech
Rest of cranial nerves are intact
MOTOR:
1 /5 in Lt upper extremity and 1/5 in Lt lower extremity
5/5 in Rt upper and lower extremity
REFLEXES: 2/4 throughout, left extensor plantar
SENSORY: decreased to touch and pain prick on left side
COORD: Normal finger to nose on right side - no dysmetria or tremors.
Gait: deferred due to weakness
