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NEUROLOGICAL PHYSICAL EXAM

Belowisasamplewriteupofapatientwithoutanysignificantphysicalexamfindings.
Pleasepretendasthoughyousawoneofdiseasecasesfromthehandoutgiveninclass&
replacethephysicalexamfindingsbelowwiththoselistedinthecase.Ifnoinformation
wasgiveninthecase,assumeanormalfinding(i.e.suchasafindingfromyourlab
partner).(4pts)
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 partners]
Resp: [insert partners]
Pulse-ox: not obtained
Height: 56
BMI: [lbs * 703 / inches2]

Pulse: [insert partners], regular


BP: [insert partners] (sitting, right arm)
Pain: 0
Weight: 135 lbs

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 and AC > BC (normal Rinne) in both ears.
Vestibular function intact (see motor/gait). The palate (IX & X) 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.

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

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, 2point 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). Cerebellarrapidly alternating movements (RAM), finger-to-nose (FN),
and heel-along-shin (HS) intact. Rombergmaintains 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.
Pleaseincludeyoursuspecteddiagnosisforthecasegivenintheclasshandout,aswell
asabrief(13sentences)justificationforyourdiagnosis.(1pt)

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