Nervous System

#Nervous System S: Subjective Presenting Complaints: (-) headache (-) seizure/fit (-) memory (-) speech (-) smell (-) vision (-) diplopia (-) hearing (-) tinnitus (-) vertigo (-) weakness (-) incoordination (-) drowsiness (-) gait (-) paraesthesia (-) sphincter (-) libido Details: Past Medical History: (-) birth trauma/hypoxia (-) head trauma (-) cranial surgery (-) meningitis (-) encephalitis (-) syphilis (-) cardiovascular disease Family History: (-) epilepsy (-) dementia, (-) other neurological conditions -> Social History: (-) alcohol use O: Objective Neurological Examination: **abnormalities** (+) yes, (-) no, (?) not tested 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: (-) biceps (C5, C6) (-) triceps (C6, C7) (-) wrist extension (C6, C7, C8, radial nerve) (-) grip (C7, C8, T1) (-) finger abduction (C8, T1, ulnar nerve) (-) thumb opposition (C8, T1, median nerve) Left: (-) biceps (C5, C6) (-) triceps (C6, C7) (-) wrist extension (C6, C7, C8, radial nerve) (-) grip (C7, C8, T1) (-) finger abduction (C8, T1, ulnar nerve) (-) 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: (-) biceps jerk (C5, C6) (-) supinator jerk (C6) (-) extensor digitorum jerk (C6, C7) (-) triceps jerk (C7, C8) Left: (-) biceps jerk (C5, C6) (-) supinator jerk (C6) (-) extensor digitorum jerk (C6, C7) (-) 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: (-) C4 (posterior aspect of shoulder) (-) C5 (lateral aspect of upper arm) (-) Right 2, Left 2: C6 (tip of thumb) (-) Right 2, Left 2: C7 (tip of middle finger) (-) Right 2, Left 2: C8 (tip of pinkie) (-) T1 (medial aspect of lower arm) Left: (-) C4 (posterior aspect of shoulder) (-) C5 (lateral aspect of upper arm) (-) Right 2, Left 2: C6 (tip of thumb) (-) Right 2, Left 2: C7 (tip of middle finger) (-) Right 2, Left 2: C8 (tip of pinkie) (-) T1 (medial aspect of lower arm) Hand sensation: 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** 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: (-) hip flexion (L2-4) (-) hip extension (S1) (-) knee extension (L2-4) (-) knee flexion (L4-S2) (-) ankle dorsiflexion (L4-L5) (-) ankle plantar flexion (S1) Left: (-) hip flexion (L2-4) (-) hip extension (S1) (-) knee extension (L2-4) (-) knee flexion (L4-S2) (-) ankle dorsiflexion (L4-L5) (-) 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: (-) knee jerk (L2, L3, L4) (-) ankle jerk (S1, S2) (-) plantar reflex (L5, S1, S2) Left: (-) knee jerk (L2, L3, L4) (-) ankle jerk (S1, S2) (-) 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: (-) L1 (iliac crest and inguinal region) (-) L2 (antero-lateral thigh) (-) L3 (knee) (-) L4 (medial lower leg, medial malleolus) (-) L5 (medial tibia, great toe and medial dorsum of foot) (-) S1 (sole and lateral side of foot) (-) S2 (calf and posterior thigh to buttock) (-) S3-5 (buttock, perianal) Left: (-) L1 (iliac crest and inguinal region) (-) L2 (antero-lateral thigh) (-) L3 (knee) (-) L4 (medial lower leg, medial malleolus) (-) L5 (medial tibia, great toe and medial dorsum of foot) (-) S1 (sole and lateral side of foot) (-) S2 (calf and posterior thigh to buttock) (-) 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** (-) Appearance (-) Behaviour (-) Motor activity (-) Speech. (-) Mood (patient subjective) (-) Affect (examiner observations) (-) Thought processes. (-) Thought content. (-) Perceptions. (-) Cognition. (-) Orientation. (-) Attention/concentration. (-) Memory. (-) Digit span. (-) Recall (of 4 items). (-) Distant recall. (-) Abstract reasoning. (-) Insight. (-) Judgement. (-) Numeric skills. (-) Construction and spatial skills. (-) Abstract thinking. Investigation Results: A: Assessment Clinical Summary: Diagnosis / DDx: P: Plan Investigations: Treatment: Referrals: Patient Education / Home Care Advice: Review:

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