Neurologic Exam Medical Transcription Phrases and Words

NEUROLOGIC EXAM: Neurologically, he is intact, moving all 4 extremities symmetrically and spontaneously with full motor strength. He has normal sensation to light touch.

NEUROLOGIC: No acute neurologic changes are noted. Again, his orientation and judgment demonstrates confusion.

NEUROLOGIC: Spontaneous eye opening, nonverbal. He has some decorticate positioning and some spasticity of the upper extremities.

NEUROLOGIC: She is alert, consolable after exam and appears nontoxic.

NEUROLOGIC: She is oriented x3. Cranial nerves are intact, 5/5 grip strength.

NEUROLOGIC EXAM: He is somnolent, arouses to verbal stimuli. He answers 1 question at a time and drifts back to sleep. Cranial nerves are otherwise intact. He has 4+/5 grip strength and equal bilaterally.

NEUROLOGIC: She is oriented x3. Cranial nerves II-XII are intact.

NEUROLOGIC: He has 2/4 reflexes at the knees bilaterally, 1+/4 reflexes at the ankles and equal bilaterally. He is able to stand on heels and toes.

NEUROLOGIC: She is alert with a social smile, following simple commands. She has a normal gait.

NEUROLOGIC EXAM: Cranial nerves II through XII are intact grossly. No focal neurologic deficits. Gait is normal. Deep tendon reflexes in upper and lower extremities are 2+ bilaterally. Sensation is intact to pinprick in upper and lower extremities bilaterally. 5/5 strength in upper and lower extremities bilaterally.

NEUROLOGIC: GCS is 15. Cranial nerves II through XII are grossly intact. Strength is 5/5 throughout. No sensation difficulties are noted. No evidence of ataxia.

NEUROLOGIC EXAM: She is moving all 4 extremities spontaneously and equally. No weakness, numbness or tingling is appreciated. She has equal bilateral grip strength. Reflexes are 2+ and symmetric bilaterally, upper and lower extremities. Finger-nose-finger and Romberg testing is normal. No evidence of ataxia. Gait is normal, non wide-based.

NEUROLOGIC EXAM: Do not appreciate any frank deficits. The patient is somewhat noncooperative, and she seems to be altering her physical exam. Cranial nerves II-XII appear to be intact; however, she does not want to cooperate with extraocular muscle movements. I asked her to stick out her tongue and she initially sticks it straight out and then moves it to the left. I then asked her to smile and she smiles normally, but then sort of moves the right side of her lower lip off to the side, and I can actually see the muscles of her face contracting to make this grimace and make her smile asymmetric. Also, she will hardly comply with strength testing in her upper extremities but was able to use her bilateral upper extremities to grab the rails on her bed and pushed herself up from a lying to a sitting position. She was able to lift her own weight essentially up off the bed without difficulty, but then when I asked to test her strength, she acted as if she could barely lift her arms up off the bed. Her DTRs are symmetric and intact to the upper and lower extremities. She has a normal Babinski reflex with toes downgoing bilaterally. Her sensation is grossly intact throughout, and she is able to move all 4 extremities, and she ambulated to and from the bathroom without difficulty.

NEUROLOGIC: He has no focal deficits. Cranial nerves II through XII are grossly intact. Sensation is intact throughout. He is moving all 4 extremities. Follows complex commands. DTRs are symmetric and intact in upper and lower extremities. Strength is symmetric and intact throughout, and he has no pronator drift. Equal and symmetric finger-to-nose coordination. He is able to walk with an uneven steady gait; however, when you ask him to turn around, he does seem to be just a little bit off balance, and he gets extremely off balance with heel-to-toe walking. He is able to a heel-to-shin test bilaterally without difficulty and has a negative and normal Romberg testing.

NEUROLOGIC EXAM: She has no focal neurologic deficits. Cranial nerves II through XII are grossly intact. Sensation is intact throughout. She is moving all 4 extremities. Follows complex commands. She has no pronator drift. Equal and symmetric finger-to-nose coordination. Strength is +5/5, symmetric and intact. DTRs are symmetric and intact to the upper and lower extremities. I did administer portions of mini-mental status exam, and she can tell me her name, her daughter’s name, where she is. She gets a little confused on the day of the week, but she states that is typical for her, and she is able to tell me the year and who the president is. She is completely unable to do serial 7s, cannot even begin to tell me 100-7 and is able to spell “world” forward but did not spell it backwards at all. In fact, gives me numerals when she tries to spell it backward. However, she is not having any word finding difficulties, is completely appropriate with clear speech.

NEUROLOGIC: GCS of 15. Cranial nerves II through XII grossly intact. He has normal strength in upper and lower extremities. He has no pronator drift. Normal finger-to-nose. Normal rapid alternating movements. Negative Romberg and normal gait.

NEUROLOGIC: No gross motor sensory deficits. The patient is alert, cooperative and exhibits intact distal sensation in all digits of left foot.

NEUROLOGIC EXAM: Alert and oriented x3, normal mental status. Cranial nerves II-XII intact. Strength 5/5 bilaterally throughout. There is no pronator drift. Subjectively, the patient does have decreased sensation to light touch in the right upper and right lower extremity as compared with the left; however, objectively, her sensation is intact to light touch. Deep tendon reflexes 2+ bilaterally. Station and gait within normal limits. Negative Romberg sign. No cerebellar signs.

NEUROLOGIC: A&O x4. GCS 15. He has 5/5 strength throughout. Normal gross sensation throughout. 2+ deep tendon reflexes in patellar tendons and biceps tendons bilaterally.

NEUROLOGIC EXAM: A&O x4, 5/5 strength throughout. Normal gait. No dysarthria, no dysmetria, no pronator drift. 2+ deep tendon reflexes in patellar tendons and biceps tendons bilaterally.

NEUROLOGIC: The patient is alert and oriented x3. The patient’s gross sensation to touch intact. Cranial II-XII grossly intact. Tandem gait is normal. Heel-to-toe is normal.

NEUROLOGIC: He is neurologically intact to gross touch and sharp and dull. The patient is awake, alert and oriented x3. The patient has 5/5 strength in all extremities.

NEUROLOGIC EXAM: Cranial nerves II-XII grossly intact. Strength is 5/5 throughout. Sensation is intact and symmetric. Gait is normal. Romberg is negative. Cerebellar function tests are appropriate and symmetric. He is able to ambulate on his toes. He is able to ambulate on his heels. He has no saddle anesthesia. Straight leg raise reproduces his pain on the right side. Straight leg raise on his left leg does not reproduce the pain.

NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves II through XII are intact except for left central 7th nerve paresis, left homonymous hemianopsia. Sensation was decreased in stocking-glove fashion in the extremities. Babinski was positive on the left. Deep tendon reflexes were exaggerated on the left. Sitting balance was good. Standing balance was impaired.

NEUROLOGIC: Cranial nerves I-XII grossly intact. Cerebellar function of finger-to-nose and toe-to-toe walking is WNL. Strength is 4+ throughout on all 4 extremities.

NEUROLOGIC EXAM: She is alert and oriented in all 3 spheres. Normal speech and language function. Memory is intact in all modalities. Pupils are 3 mm, round, and reactive to light and accommodation. No visual field deficits. Extraocular movements are full. No nystagmus. No facial asymmetry. Auditory canals are intact. Muscle bulk and tone are within normal limits. No evidence of any focal motor or sensory deficits. Intact deep tendon reflexes. Plantar response is downgoing bilaterally. Finger-to-nose test did not show any ataxia. Gait is not tested at this time.

NEUROLOGIC: He is alert and oriented, able to follow 3-step commands. Cranial nerves II through XII are grossly intact. Sensation is patchy in the lower extremities. The patient did have proprioception in the greater toe on the left lower extremity but absent on the right, and bulbocavernosus reflex was absent. The patient had no reflexes in the lower extremities. Reflexes were present in the upper extremities.

NEUROLOGIC EXAM: Mental status as above. The patient is able to point to his right hand. Graphesthesia and stereognosis was not tested. Light touch was not tested. Motor exam: Essentially right dense hemiparesis with only trace adduction at the shoulder and hip on the right side, left side is within normal limits. The right upper extremity is flaccid. Reflexes are diminished in the right upper extremity; in the right lower extremity, toes are upgoing. Tone is essentially flaccid as well, and reflexes are unable to be obtained at the knee.

NEUROLOGIC: Awake, alert, articulate, oriented x3. Cranial nerves II through XII are intact. Motor and sensory are equal and intact. Toes are downgoing. Heel-to-shin and finger-to-nose are completely normal.

NEUROLOGIC EXAM: Alert and oriented x3. Speech was a little bit slurred, but his mentation was intact. His motor and sensory were intact. His gait was steady.

NEUROLOGIC: Oriented x3. Normal gait. No muscle atrophy or tremor. Cranial nerves II through XII are intact. Normal strength, sensation and coordination. Babinski is downward. No focal motor or sensory deficits. DTRs 2/4.

NEUROLOGIC: The patient has negative Tinel, negative Valleix, negative clonus, negative Babinski. The patient does have diminished 5.0 Semmes-Weinstein filament over the fifth metatarsal head to the right. The patient has long, thick dystrophic toenails, tender upon palpation. Skin inflamed, especially under the nail bed of fourth toe to the left. Nails are roughly 6 to 8 mm in thickness. Nails are yellow, dystrophic, crumbly, resembling onychomycosis.

NEUROLOGIC EXAM: The patient is awake, alert and oriented to time, place and person. Could tell year, month, and name of the president and no aphasia or dysarthria. Cranial nerve exam shows pupils are reactive. Disks are sharp. Visual fields are full. Extraocular movements are normal. Face is symmetrical. Tongue is midline. Gag is intact. Sternomastoid and trapezius are normal. Motor system exam reveals normal tone and strength in upper and lower extremities. Deep tendon reflexes are +2 at the biceps, +2 at the triceps, +2 at knees. Plantars are flexor. No sensory signs. Cerebellar exam reveals finger-to-finger and finger-to-nose intact; however, the patient was severely ataxic on sitting.