Tonyj
True Blue
Does this meet comprehensive physical exam under the '97 neurology guidelines?
PHYSICAL EXAMINATION:
Vital Signs: Temp 98.2, BP 103/74, P 121 (regular), RR 20 (unlabored), WT 193 pounds.
General: Small, healed ulcer in the pilonidal region. Healthy-appearing man, well groomed, and without deformities.
Mental Status: Awake, alert and attentive. No psychomotor slowing. Intact immediate and delayed recall. Fluent speech with intact naming and repetition. Normal fund of knowledge.
Cranial Nerves: II: Full fields. III, IV, VI: Pupils round and reactive. Full extraocular movements. No nystagmus. V: Normal bite and sensation. VII: No weakness. VIII: Hearing intact. IX, X: Palate midline. XI: Sternocleidomastoids normal. XII: Tongue midline. No dysarthria.
Motor: Normal bulk and tone. Power full throughout, perhaps very subtle weakness on hip flexion of the left leg. No abnormal movements.
Sensation: Decreased in glove and stocking distribution in the toes and fingers to vibration. Also subjective loss in lateral femoral cutaneous distribution of the left leg and the anterolateral thigh.
Coordination: No dysmetria or dysdiadochokinesis bilaterally.
Gait: Normal including heel and toe walking.
Reflexes: Hypoactive and symmetric throughout. Absent Babinski sign bilaterally.
Vascular: No peripheral edema. Normal peripheral pulses. No carotid bruits.
Eyes: Funduscopic exam reveals no papilledema.
PHYSICAL EXAMINATION:
Vital Signs: Temp 98.2, BP 103/74, P 121 (regular), RR 20 (unlabored), WT 193 pounds.
General: Small, healed ulcer in the pilonidal region. Healthy-appearing man, well groomed, and without deformities.
Mental Status: Awake, alert and attentive. No psychomotor slowing. Intact immediate and delayed recall. Fluent speech with intact naming and repetition. Normal fund of knowledge.
Cranial Nerves: II: Full fields. III, IV, VI: Pupils round and reactive. Full extraocular movements. No nystagmus. V: Normal bite and sensation. VII: No weakness. VIII: Hearing intact. IX, X: Palate midline. XI: Sternocleidomastoids normal. XII: Tongue midline. No dysarthria.
Motor: Normal bulk and tone. Power full throughout, perhaps very subtle weakness on hip flexion of the left leg. No abnormal movements.
Sensation: Decreased in glove and stocking distribution in the toes and fingers to vibration. Also subjective loss in lateral femoral cutaneous distribution of the left leg and the anterolateral thigh.
Coordination: No dysmetria or dysdiadochokinesis bilaterally.
Gait: Normal including heel and toe walking.
Reflexes: Hypoactive and symmetric throughout. Absent Babinski sign bilaterally.
Vascular: No peripheral edema. Normal peripheral pulses. No carotid bruits.
Eyes: Funduscopic exam reveals no papilledema.