Nervous system

{Nervous system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment
      
PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms {abnormalities}
[-] headache
[-] neuropathic pain
[-] seizures/fits
[-] memory
[-] speech
[-] smell
[-] vision
[-] diplopia
[-] hearing
[-] tinnitus
[-] vertigo
[-] weakness
[-] incoordination
[-] drowsiness
[-] gait
[-] paraesthesia
[-] sphincter
[-] libido

History of presenting complaint:
-

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

History since last contact:
-

Patient's or carer's ideas, concerns and expectations:
-

PAST MEDICAL HISTORY
Relevant past medical history:
[-] birth trauma/hypoxia
[-] head trauma
[-] cranial surgery
[-] meningitis
[-] encephalitis
[-] syphilis
[-] cardiovascular disease
[-] atrial fibrillation
[-] hypertension

FAMILY HISTORY
Relevant family history:
[-] epilepsy
[-] dementia, 
[-] other neurological conditions:

SOCIAL HISTORY
Smoking:
[-] never smoked
[-] current smoker
[-] ex-smoker
  If smoker, pack-year history:

Alcohol intake:
[-] nil
[-] alcohol use
  If yes, standard drinks per week:

PHYSICAL EXAMINATION
Neurological Examination: {abnormalities}

Heart rate (bpm): 
  Blood pressure (mmHg): 
  Temperature (deg.C):

[-] posture
[-] gait
[-] skull
[-] spine
[-] neck stiffness
[-] photophobia
[-] carotid bruits
[-] heart murmurs

----------
CRANIAL NERVES:

[I] Olfactory nerve (olfaction): 
[-] right 
[-] left

(II) Optic nerves:

Visual acuity - distance (Snellen chart) [6/6]: 
- Right ?/6 
- Left ?/6 
Visual acuity - near {Times Roman card @ 40 cm} [N5]: 
- Right N?
- Left N?
Visual fields (confrontation): 
[-] right 
[-] left

Pupillary reflexes {light/accommodation} [equal and reactive]: 
[-] right 
[-] left 
Ophthalmoscopy {cornea, lens, fundus}: 
[-] right 
[-] left

Colour vision (Ishihara plates) errors:

Eye movements (mnemonic 3LR6SO4):
  IV - superior oblique - moves the eye down and out
  VI - lateral rectus - moves the eye outward
  III - all other movements

[-] right 
[-] left

(V) Trigeminal nerve: 
Sensory (facial sensation: 3 divisions - mandibular, maxillary, frontal: 
[-] right 
[-] left 
Motor {muscles of mastication - temporalis, masseter}: 
[-] right 
[-] left

[-] jaw jerk reflex

(VII) Facial nerve: 
Muscles of facial expression: 
[-] right 
[-] left

Taste: 
[-] right 
[-] left

(VIII) Vestibulocochlear nerve: 
Hearing acuity {whisper test}: 
[-] right 
[-] left 
Rinne test: 
[-] right 
[-] left 
[-] Weber test {central}
[-] Vestibular function (nystagmus, sharpened Romberg)

Auriscope examination: 
[-] right 
[-] left

(IX) Glossopharyngeal nerve/X Vagus nerves: 
[-] Gag reflex
[-] Soft palate movement

(XI) Spinal accessory nerve (supplies sternomastoid and trapezius muscles, test by a shrug of shoulders and head rotation): 
[-] right 
[-] left

(XII) Hypoglossal nerve (tongue motor supply): [-] movement, [-] muscle bulk, [-] tongue fasciculation.

----------
UPPER LIMBS {abnormalities}

Upper limb muscle wasting:
Arm circumferences measured the same distance above and below the elbows with the arm in a neutral posture.

[-] Right upper arm
[-] Right forearm
[-] Left upper arm
[-] Left forearm

Upper Limb Motor Power:

Motor power grading: 0 = no contraction, 1 = slight contraction and no movement, 2 = active movement with gravity eliminated, 3 = active movement against gravity only, 4 = active movement against resistance but reduced, 5 = normal active movement against resistance, NT = not testable.

Right:
5 : biceps - C5, C6 
5 : triceps - C6, C7 
5 : wrist extension - C6, C7, C8, radial nerve 
5 : grip - C7, C8, T1 
5 : finger abduction - C8, T1, ulnar nerve 
5 : thumb opposition - C8, T1, median nerve

Left:
5 : biceps - C5, C6 
5 : triceps - C6, C7 
5 : wrist extension - C6, C7, C8, radial nerve 
5 : grip - C7, C8, T1 
5 : finger abduction - C8, T1, ulnar nerve 
5 : thumb opposition - C8, T1, median nerve

Grip strength: {abnormalities}
  Right (kg): 
  Left (kg):

Involuntary movements: (Tremor, athetosis, tics): 
[-] right
[-] left

Upper Limb Deep Tendon Reflexes: {abnormalities}

Reflex grading: 0 = no response, 1 = decreased, 2 = normal, 3 = increased, 4 = increased with clonus, NT = not testable.

Right:
2 : biceps jerk - C5, C6 
2 : supinator jerk - C6 
2 : extensor digitorum jerk - C6, C7 
2 : triceps jerk - C7, C8

Left:
2 : biceps jerk - C5, C6 
2 : supinator jerk - C6 
2 : extensor digitorum jerk - C6, C7 
2 : triceps jerk - C7, C8

Dermatomal Sensation: (Light touch, pinpoint) *abnormalities*

Sensory grading (compare with the face as the normal control): 0 = absent (anaesthesia), 1 = altered or reduced, 2 = normal.

Right:
2 : C4 - posterior aspect of shoulder 
2 : C5 - lateral aspect upper arm 
2 : C6 - tip of thumb 
2 : C7 - tip of middle finger 
2 : C8 (tip of pinkie 
2 : T1 - medial aspect of lower arm

Left:
2 : C4 - posterior aspect of shoulder 
2 : C5 - lateral aspect upper arm 
2 : C6 - tip of thumb 
2 : C7 - tip of middle finger 
2 : C8 (tip of pinkie 
2 : T1 - medial aspect of lower arm

Hand sensation: {abnormalities}

Two-point discrimination: 
    [-] right 
    [-] left 
  Touch localisation: 
    [-] right 
    [-] left 
  Stereognosis (ability to perceive the form of solid objects by touch): 
    [-] right
    [-] left
  Graphaesthesia (ability to identify writing on the skin by sensation): 
    [-] right
    [-] left

----------
LOWER LIMBS {abnormalities}

Muscle wasting:
[-] right thigh 
[-] right calf 
[-] left thigh 
[-] left calf

Active ranges of motion: {abnormalities}

[-] flexion [60+] 
[-] extension [25+] 
[-] lateral flexion [25+] 
[-] rotation [30+]: right

Motor power: {abnormalities}

Right:
5 : hip flexion - L2-4 
5 : hip extension - S1 
5 : knee extension - L2-4 
5 : knee flexion - L4-S2 
5 : ankle dorsiflexion - L4-L5 
5 : ankle plantar flexion - S1

Left:
5 : hip flexion - L2-4 
5 : hip extension - S1 
5 : knee extension - L2-4 
5 : knee flexion - L4-S2 
5 : ankle dorsiflexion - L4-L5 
5 : ankle plantar flexion - S1

Deep tendon reflexes: {abnormalities}
Reflex grading: 0 = no response, 1 = decreased, 2 = normal, 3 = increased, 4 = increased with clonus, NT = not testable.

Right:
2 : knee jerk - L2, L3, L4 
2 : ankle jerk - S1, S2 
2 : plantar reflex - L5, S1, S2

Left:
2 : knee jerk - L2, L3, L4 
2 : ankle jerk - S1, S2 
2 : plantar reflex - L5, S1, S2

Sensation: (Light touch, pin-point) {abnormalities}
Sensory grading (compare with the face as the normal control): 
0 = absent (anaesthesia), 1 = altered or reduced, 2 = normal.

Right:
2 : L1 - iliac crest and inguinal region 
2 : L2 - antero-lateral thigh 
2 : L3 - knee 
2 : L4 - medial lower leg, medial malleolus 
2 : L5 - medial tibia, great toe and medial dorsum of foot 
2 : S1 - sole and lateral side of foot 
2 : S2 - calf and posterior thigh to buttock 
2 : S3-5 - buttock, perianal

Left:
2 : L1 - iliac crest and inguinal region 
2 : L2 - antero-lateral thigh 
2 : L3 - knee 
2 : L4 - medial lower leg, medial malleolus 
2 : L5 - medial tibia, great toe and medial dorsum of foot 
2 : S1 - sole and lateral side of foot 
2 : S2 - calf and posterior thigh to buttock 
2 : S3-5 - buttock, perianal

Slump sign: 
[-] left
[-] right

----------
Cerebellar Function: {abnormalities}

[-] Gait.
Finger-nose-finger: 
  [-] right
  [-] left
Heel-knee:
  [-] right
  [-] left
Alternating movements (hand flipping, foot tapping):
  [-] right
  [-] left

----------
Mental State Observations: {abnormalities}

[Mental state observations]

Abnormalities:
[-] appearance
[-] behaviour
[-] motor activity
[-] speech
[-] mood (patient [-] subjective)
[-] affect (examiner [-] observations)
[-] thought processes
[-] thought content
[-] perceptions
[-] cognition
[-] orientation
[-] attention/concentration
[-] memory
[-] abstract reasoning
[-] insight
[-] judgement
[-] numeric skills
[-] construction and spatial skills
[-] abstract thinking

Comments:

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

patient information and advice:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260201]

Nervous system

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