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Documenting a Neuro Exam (If It’s All Normal):

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MSE

  • Awake, Alert, Oriented to Person, Place, and Time
  • Naming and repetition intact
  • Attention intact ("world" backwards)
  • Short term memory intact (3/3 recall)
  • Long term memory intact (president recall)

CN

  • II: Visual acuity 20/20 L and R, VFF, blinks to confrontation, FUNDI: no blurring of disk margins, nl vessels
  • III, IV, VI: PERRLA, EOMI
  • V: normal sensation to light touch, normal jaw strength, corneal reflex intact
  • VII: face symmetric at rest and on activation; no nasolabial fold flattening
  • VIII: normal hearing to conversation
  • IX,X: uvula midline, rises with phonation
  • XI: shoulder shrug 5/5
  • XII: tongue midline

Motor

  • Normal bulk and tone
  • No abnormal movements

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  • WE/WF (wrist ext/flex), DI (dorsal interossei), HF (hip flex), KE/KF (knee/flex),
  • DF (dorsiflex), PF (plantarflex)

Sensory

  • sensation intact to light touch, pinprick, vibration, proprioception

Reflexes

  • Brachioradialis, biceps, triceps 2+ bilaterally
  • Patella, and ankles 2+ bilaterally.
  • Negative Babinski
  • No abnormal reflexes (Hoffman, Cross Adduction, Pectoral Spread)

Coord

  • No dysmetria on FNF, no dysdiadochokinesia on RAM, HTS intact

Gait

  • Normal balance and gait, able to walk on toes/heels, able to tandem walk