Upon evaluation of comprehension patient able to follow stages 1 and 2 of

Upon evaluation of comprehension patient able to

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sevens test performed accurately. Upon evaluation of comprehension patient able to follow stages 1 and 2 of comprehension. Has accuracy of general knowledge upon evaluation. When testing for observation remote memory immediate memory,and new learning ability all accurate and intact. Observe vocabulary expected complex for age education level in general ability intact. Observe articulation no problems noted with expression or pronunciation. CN I- with smell test intact CN II- optic test visual Acuity right 20/40, noted myelinated nerve fibers cotton wool bodies and sharp right disc margin. left 20/20 and left fundus no visible abnormal findings left disc margin sharp , PERRL CN III, IV, VI- all EOM intact, no abnormal findings. CN V- intact CN VII- inspected and symmetric CN VIII- Weber test normal, and Rinne test normal bilateral CN IX, X- gag reflex intact CN XI- shoulders symmetric and strength a 5 neck bilateral a stength 5 CN -XII - no abnormal findings and symmetric. All cranial nerves noted intact. Deep tendon reflexes tested- triceps, biceps, brachioradialis,patellar and achilles bilaterally intact 2+as expected. Upon testing motor skills finger to nose bilaterally smooth and accurate. Heel to shin bilaterally smooth and accurate. Observe rapid alternating hand movements is smooth and performed without difficulty. Patients gait is steady with no sign of asymmetry or imbalance. Graphesthesia tested right pt able to identify by letter identification and left by number identification. Tested sensation in the arms and legs bilaterally expected normal and intact in for dull, soft and sharp sensations. Sensation to feet bilateral are decreased position sense bilateral fingers and toes intact. Able to identify from sterognosis test object in right and left hand. General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable while sitting in exam chair. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic • Eyes: Bilateral eyes with equal hair distribution. • Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to- shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with
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  • Fall '15
  • Headaches, Ms. Jones

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