1995 Guidelines

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Given this example, where would you give credit in the exam portion? and would you assign any of these as a complete organ system review?

Cranial Nerves: CN II Right: pupil normal size and reactive to light and dark. CN II Left: pupil normal size and reactive to light and dark. CN III, IV, VI: rotatory nystagmus. CN V Right: normal sensation. CN V Left: normal sensation. CN VII Right: normal facial expression. CN VII Left: normal facial expression.


Motor Exam: Right Upper Extremity: normal bulk and tone. Left Upper Extremity: normal bulk and tone. Right Hand: FROM and hand grip 5/5. Left Hand: FROM and hand grip 4+/5. Right Lower Extremity: spastic. Left Lower Extremity: spastic.

Reflexes: Reflexes Right: biceps 3/4, triceps 3/4, brachial radialis 3/4, patellar 3/4, and achilles 3/4. Reflexes Left: biceps 3/4, triceps 3/4, brachial radialis 3/4, patellar 3/4, and achilles 3/4. Plantar Reflex Right: response downgoing. Plantar Reflex Left: Babinski present. Coordination: normal finger-to-nose and heel-to-shin, no clonus or pronator drift, and rapid alternating movements normal. Sensation: normal pinprick, temperature, vibration, position, and light touch. Gait/Posture: unsteady station; spastic gait.


your input would be appreciated.
Thank you
 

jonique.dietzen

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I would consider that exam detailed under the 1995 guidelines and Expanded Problem Focused under the 1997 guidelines.

A complete neurological exam should include cranial nerves 2-12 and a review of mental functions.

Jonique Dietzen, CPC
 
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