I was wondering if I could get some help with the exam portion of a neuro exam, I am using the neuro speciality sheet.
On examination, she weighs 253 lbs with a bp of 142/72 and a regular pulse of 60. Sppech and language are normal during casual conversation as were her cognitive abilities and affect during casual conversation. Ther are no bruits auscultated over her head or neck. Visual fields are full to confrontation. Pupils were 3 mm, equal and slightly reactive. There is no pupillary defect. Eye movements are full w/o nystagmus. her face was symmetric and tongue and palate are midline. No tremor about hte head was noted. Sternocleiodomastoid muscles were normal. Motor exam demonstrated normal tone throughout. Ther is no pronator drift or asterixis. fine motor movements were a little apraxic and slow especially with rapid alternating movements, more so on the left hand thatn the right. On finger to nose testing it is performed accurately, but there is clearly an action tremor evident and a minumal amount of postural tremor is noted. There is a little bit of rest remor suggested at times in her fingers more on the lefrt than the right. Asking her to draw an archimedes spiral, there is a slow angulation of the corkscrew line. Teh reflexes are 1+ and symmetric throughout with toes bilaterally downgoing. Sensory exam intact to pinprick, vibration, and there is no neglect. Watching her walk, her gait appeas somewhat stiff, possibly due to problems with her knees, but her left arm seems to swing a little less than the right.
I don't normally audit neuro records but I got one today...
At this point what I have is:
Cardio: bullet one
const: bullet one
eyes: bullet 1
musc: bullet one
Neuro bullet 4, the following cranial nerves 2nd, 3,4 and 6, 7,9,12 exam of sensation
exam of deep tendon (babinski)
I feel like I am missing something but like I said I don't normally audit neurology.
If anyone sees something I am missing, by all means let me know.
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