Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the neurologic system.

• The patient is oriented to person, time, and place. Cranial nerves II to XII are intact. Motor examination reveals normal gait, normal heel-to-toe movement, and normal strength bilaterally. Reflexes are equal bilaterally and are within normal limits. The sensory examination results are normal, with pain, light touch, and stereognosis intact. Cerebellar function is normal.

• The mental status examination results are within normal limits. There is a marked weakness of the lower half of the right side of the face. The right na-solabial fold is flat, and the mouth droops downward on the right. There is no other cranial nerve abnormality. The motor and sensory examination results are within normal limits. Reflexes are normal. Romberg test result is negative.

• The patient has an expressive aphasia and a right hemiplegia with ipsilateral trigeminal hemiplegia. Reflexes in the right lower extremity are hyperactive in comparison with the left. Sensory examination is difficult to assess. Babinski's sign is present on the right side.

• Mental status is within normal limits. Motor examination results and reflexes are equal bilaterally. There is a sensory level at L2 on the right and at L4 on the left. Vibration sense is impaired more on the right than on the left, as is position sense. Romberg test result is positive.

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