NEUROLOGICAL PHYSICAL EXAM

General
Mrs. ---------is 35 y/o right-handed hindu 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.

Neurological
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. Sensations 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 fasciculations.

Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4 bilaterally; no clonus. Plantar
(Babinski) is downgoing bilaterally.

OR

Biceps Brachioradialis Triceps Knee Ankle Plantar

Right 2+ 2+ 2+ 2+ 2+ - Babinski, - clonus
Left 2+ 2+ 2+ 2+ 2+ - Babinski, - clonus

Sensory: Intact bilaterally for pain (spinothalamic tract), position & vibration (posterior columns), along
with light touch. Cortical discrimination intact with: localization, 2-point 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).
Cerebellarrapidly alternating movements (RAM), finger-to-nose (FN), and heel-along-shin (HS)
intact. Rombergmaintains 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.

synched 1/10 with Neuro_PE_1-9-10 and Bates 10th ed. p 710