Normal Hospital Exam:

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Vitals: Temp ***, HR ***, RR ***, BP ***, O2sat ***% room air

General:  ***

Head:  Atraumatic

Oral Cavity:  Mucosa moist

Lungs: Normal work of breathing

Heart: RRR

Abdomen: No distention

Extremities: No edema

Skin: No rash on visualized areas

Neuro:

MS- Awake, remains alert throughout exam. Recalls a coherent history. Oriented to name, age, location, year, month. Language fluent with intact naming of low frequency items and intact repetition. Follows two-step digit specific commands crossing the midline. 

CNs- Pupils 4->3mm OU, brisk. No ptosis. VF full to finger counting. EOM full without nystagmus. Face symmetric. Tongue midline. 

Motor- 5/5 in bilateral upper and lower extremities. No atrophy, normal tone. No tremor or asterixis.

Sensation- intact to light touch on the face, upper extremities, and lower extremities without extinction. Distal position sense intact. 

Reflexes- 2+ and symmetric except 1+ ankle jerks, plantars down BL

Coordination- No dysmetria on finger-nose-finger or heel to shin testing. Romberg negative. 

Gait- Walks steadily with narrow base, able to walk on heels and tiptoes, able to tandem walk

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Super Detailed Exam:

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Gen: NAD, non-toxic appearing, resting comfortably

HEENT: NC/AT, non-icteric, MMM, supple neck, FROM without pain, no meningismus

Card: RRR, no M/G/R

Pulm: CTAB

Abd: S/NT/ND/BS+

Ext: Warm, No rashes, no edema

 

Neurologic examination:

 

Mental status:

Alertness: Awake, alert, attentive, makes eye contact.

Orientation: Oriented to person, place, time, setting.

Concentration: Can spell WORLD backwards. Follows multi-step commands without difficulty including those crossing the midline.

Memory: Patient registers 3/3 and recalls 3/3 items at 5 minutes. Recent and remote memory intact.

Language: Fluent, no aphasia, normal comprehension. Naming and reading normal.

Calculation: Intact to quarters in $1.50.

Frontal release signs: Absent.

Mood and affect: Euthymic, normal affect

 

Cranial nerves:

II: Visual fields are full to confrontation. Pupils are 4 mm and briskly reactive to light. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Visual acuity is 20/20 bilaterally. No red desaturation.

III, IV, VI: At primary gaze, there is no eye deviation. No ptosis. EOMs full in all directions. Convergence intact. No nystagmus, normal saccades.

V: Facial sensation is intact to light touch in all 3 divisions bilaterally.

VII: Face is symmetric with normal eye closure and smile. No droop.

VII: Hearing is normal to conversation.

IX, X: Palate elevates symmetrically. Phonation is normal.

XI: Head turning and shoulder shrug are normal.

XII: Tongue is midline with normal movements and no atrophy.

 

Motor: There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally.

R/L:

Deltoid 5/5   Biceps 5/5   Triceps 5/5  Wrist extension 5/5  Finger extension 5/5 flexion 5/5 

Hip flexion 5/5   Hip adduction 5/5   Hip abduction 5/5   Knee flexion 5/5

Knee extension 5/5   Ankle flexion 5/5   Ankle extension 5/5 

 

Reflexes: Reflexes are 2+ and symmetric at the biceps and triceps. They are 2+ and symmetric at the knees and ankles. Plantar responses are flexor.

 

Sensory: Light touch, temperature, and vibration sense intact in upper and lower extremities. Pinprick intact. Position sense intact in fingers and toes. No extinction.

 

Coordination: There is no dysmetria on finger-to-nose. Normal heel-knee-shin. There are no abnormal or extraneous movements. No tremor. Rapid alternating movements and fine finger movements are intact. 

 

Gait/Stance: Posture is normal. Romberg is absent. Gait is steady with narrow base, normal steps, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal.

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ICU Neurologic Exam:

 

Gen: Critically ill, intubated, mechanically ventilated, lying supine

HEENT: NC/AT, non-icteric, MMM, supple neck

Card: RRR, no M/G/R

Pulm: Course vented breath sounds b/l

Abd: S/ND/BS+

Ext: Warm, No edema, no rashes

 

Neurologic examination:

 

MS: Unarousable to name or sternal rub, no receptive/expressive language

 

CN: 

II:  visual threat:  blinks. Eye squints to bright light. R pupil 4mm -> 3mm, L pupil 4mm -> 3mm, and brisk. Fundoscopic exam is normal with sharp discs and no vascular changes.

III, IV, VI: does not track. Oculocephalic reflexes reveal intact motor movements.

V: corneal reflexes intact, nares tickling provokes grimace.

VII: No droop, symmetrical facial grimace to pain.

VIII: Does not respond to sound, cold calorics reveal nystagmus with fast phase away from ice.

IX/X: gag reflex intact, cough intact.

 

M: No flexor or extensor posturing in 4 extremities. Does not follow motor commands, Normal muscle bulk and tone, no myoclonus.

 

S: Withdraws to pain in 4 extremities.

 

R: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor.

 

GCS: Motor: Withdraws to pain, Verbal: no response, Eyes: closed.

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LP Procedure Note

Procedure Note: Lumbar puncture

Indication: ****    

PERMIT:  The risks and benefits of the procedure were discussed with the patient.  Risks include, but are not limited to, pain, bleeding, headache and infection.  The patient elected to proceed and a signed procedure consent is in the medical record.

Time Out procedure was performed and accurate. The complete and accurate Time Out procedure included: patient verification (2 identifiers) and verification of procedure (LP).

Consent: In chart     

Prepped and draped in usual fashion.    

**** ml of 1% lidocaine to skin and subcutaneous tissues.

22 gauge spinal needle entered  interspace .     

Opening pressure:***  cmH20

Volume of clear CSF taken: ***  ml in 4 tubes

     

The patient tolerated the procedure well. There was no blood loss or hematoma.

Sent for:

cell count, 

protein,

glucose,

Gram stain,

culture,

CrAg,

Lyme,

ACE,

OCBs,

MBP,      .

 

DISPOSITION:  After the procedure the patient was (alert, oriented, ambulatory and voicing no specific complaints).

Post Lumbar puncture instructions were given to the patient including what to do in the event of a post-lumbar puncture headache