Monday, November 16, 2020

Neurology examination template

Hi everyone!

Here is my template for documenting the basic bare minimum neurology examination.

Neurology basic physical examination template
Mental Status: Affect, Memory, Attention Span, Concentration, and Fund of Information - normal. Oriented to person, place, and time.
Language: intact naming, repetition, comprehension.
Speech: No dysarthria, no aphasia, no speech apraxia
CN 2: symmetric visual fields.
CN 3, 4, 6: Extraocular muscle movements intact, pupils equally reactive to light.
CN 5: symmetric facial sensation.
CN 7: symmetric facial expression, no nasolabial fold flattening.
CN 8: grossly intact hearing to finger rub and whispering.
CN 9, 10: symmetric palate elevation.
CN 11: trapezius 5/5 symmetric, sternocleidomastoid 5/5 symmetric.
CN 12: no fasciculations, no tongue deviation.
Motor: No atrophy, rigidity, or spasticity. Normal bulk.
Strength: 
Strength Right Left 
Deltoids 5/5 5/5 Triceps 5/5 5/5 Biceps 5/5 5/5 Brachio 5/5 5/5 Wrist Flex 5/5 5/5 Wrist Ext 5/5 5/5 Finger Flex 5/5 5/5 Finger Ext 5/5 5/5 Inteross 5/5 5/5
Hip ABD 5/5 5/5 Hip ADD 5/5 5/5 Hip Flex 5/5 5/5 Hip Ext 5/5 5/5 Knee Flex 5/5 5/5 Knee Ext 5/5 5/5 Dorsiflex 5/5 5/5 Plantarflex 5/5 5/5
Reflexes: Bic Tric Br KJ AJ Plantar Left 2 2 2 2 2 flexor Right 2 2 2 2 2 flexor.
Sensation: No deficit in vibration, soft-touch, pin-prick sensation, or proprioception.
Position: No deficit, symmetric.
Cerebellar: Intact finger to nose, heel to the shin, no disdiadochokinesia, no dysmetria, no gait abnormalities, intact Romberg's.
Coordination: finger-to-nose normal; heel-to-shin normal; no dysmetria.
Gait: normal gait.

Neurology physical examination in intubated patients in the ICU template
Mental Status: Intubated, sedated / off sedation for over 48 hours.
The patient does not follow commands / Patient follows commands. 
Initiates breaths on the ventilator / does not initiate breaths on the ventilator.
Speech: Intubated, unable to assess.
CN 2: Pupils pinpoint. / Pupils are equal and reactive to light. / Pupils fixed and dilated.
CN 3, 4, 6: No clear response to oculocephalic maneuver. / Eyes midline. / Oculocephalic reflex intact.
CN 5: No corneal reflex appreciated. / Corneal reflex intact bilaterally.
CN 7: No clear facial asymmetry.
CN 8: Unable to test.
CN 9, 10: No gag reflex on suctioning. / Gag reflex noted on suctioning.
CN 11: Unable to test at this time.
CN 12: Intubated.
Motor: Does not withdraw to painful stimuli. / Minimal withdrawal to painful stimuli in all 4 extremities.
Reflexes: Diminished throughout. / Normal reflexes throughout. 
No response to plantar reflex. / Downward response of the hallux or flexor plantar response (Babinski absent). / Upward response of the hallux or extensor plantar response (Babinski present).
Sensation: Does not withdraw to painful stimuli. / Minimal withdrawal to painful stimuli in all 4 extremities.
Cerebellar: Unable to test at this time.
Gait: Unable to test at this time.

-IkaN

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