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]
Resp: [insert partner’s]
Pulse-ox: not obtained
Height: 5’6”
BMI: [lbs * 703 / inches2]
Pulse: [insert partner’s], regular
BP: [insert partner’s] (sitting, right arm)
Pain: 0
Weight: 135 lbs
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.
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
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.
Biceps Brachioradialis Triceps Knee Ankle Plantar
Right 2+
- Babinski, - clonus
Left 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). Cerebellar—rapidly alternating 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