NEUROLOGICAL PHYSICAL EXAM

Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. If no information was given in the case, assume a normal finding (i.e. such as a finding from your lab partner). (4 pts)

Normal Neurological Exam

Hx obtained by: Name, M2 Student

Date, Time, Place: 1/11/09, 1:00 pm @ Carle Forum

ID: Mrs. Espanosa, a 35 y/o Latina female

CC: see cases

Vital signs

Temp: [insert partner’s] Pulse: [insert partner’s], regular

Resp: [insert partner’s] BP: [insert partner’s] (sitting, right arm)

Pulse-ox: not obtainedPain: 0

Height:5’6”Weight: 135 lbs

BMI: [lbs * 703 / inches2]

General

Mrs. Espanosa is 35 y/o right-handed Latina woman who looks her stated age.

Mental Status: Mrs. E is alert, relaxed, and cooperative. Thought process coherent. Oriented to person and place and time. She is in no apparent distress. She appears to be in overall good health and her grooming and hygiene are excellent.

Neurological

Cranial Nerves: Olfaction (I) intact by identifying the smell of coffee grounds. Visual acuity (II) is good bilaterally with 20/20 vision on hand-held chart (while wearing his corrective lenses). Visual fields are full to confrontation in all quadrants. Pupils are equally round at 3 mm and reactive to light and accommodation.Extraocular movements are intact (III, IV, VI), with no ptosis. Sensory over the face (V) is intact and equal bilaterally in all three CN V divisions for sharp, dull, and light touch stimuli. Motor is intact with midline location of the jaw and equal contraction during mastication. Facial muscle (VII) strength is normal and equal bilaterally. Hearing (VIII) is grossly intact bilaterally. Weber does not lateralize andAC > BC (normal Rinne) in both ears.Vestibular function intact (see motor/gait). The palate (IXX) and uvula elevate symmetrically, with an intact gag reflex bilaterally and a normal voice. Shoulder shrug and head turning via trapezius and sternocleidomastoid (XI) is strong and equal bilaterally. Tongue protrudes (XII) midline and moves symmetrically with no fasciculations.

Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4 bilaterally; no clonus. Plantar (Babinski) is downgoing bilaterally.

OR

Biceps / Brachioradialis / Triceps / Knee / Ankle / Plantar
Right / 2+ / 2+ / 2+ / 2+ / 2+ / - Babinski, - clonus
Left / 2+ / 2+ / 2+ / 2+ / 2+ / - Babinski, - clonus

Sensory: Intact bilaterally for pain (spinothalamic tract), position & vibration (posterior columns), along with light touch.Cortical discrimination intact with: localization, 2-point discrimination, stereognosis, and graphesthesia.Rhomberg is negative with no pronator drift.

Motor:Good muscle bulk and tone. Strength 5/5 (deltoid, biceps, triceps, quadriceps, hamstrings).Cerebellar—rapidlyalternating movements (RAM), finger-to-nose (FN), and heel-along-shin (HS) intact.Romberg—maintains balance with eyes closed. No pronator drift. Gait with normal base. Coordination is good as measured by tandem walk, heel walk, and toe walk. No asterixis.

Please include your suspected diagnosis for the case given in the class handout, as well as a brief (1 – 3 sentences) justification for your diagnosis. (1 pt)

synched 1/10 with “Neuro_PE_1-9-10” and Bates 10th ed. p 710