Name:

General Survey: The patient is awake, conscious, ambulatory, afebrile, and not in cardiopulmonary distress.
Head/Neck: No gross deformities; non-sunken eyeballs, anicteric sclerae, no eye discharges, pink palpebral conjunctiva; No ear pain/ discharge; No naso-oral discharges,
non-congested nasal turbinates; No neck masses
Lymph nodes: no cervical lymphadenopathies
LUNGS: Symmetyrical chest wall expansion, equal tactile fremitus, resonant, clear breath sounds
HEART: Adynamic precordium, no heaves/thrills, normal heart rate with regular rhythm, no murmurs, no extra heart sounds
Abdomen: Protuberant, Flabby, non-distended, no lesions, with normoactive bowel sounds, tympanitic, non-tender, no masses palpated
Not assessed
Skin: No lesions, no pallor, no jaundice, no cyanosis; warm to touch, with good skin turgor
Full and Equal peripheral pulses; no edema; good muscle tone and bulk; no limitation in range of motion
Genitalia:
Male: Tanner Stage __; normal, triangular distribution of hair; no lesions, no gross deformities, no discharges; non-tender
Female: Tanner Stage __; normal, inverted triangle distribution of hair; no lesions, no abnormal growth, no discharges; non-tender

NEUROLOGIC EXAMINATION

Glasgow Coma Scale 15 (E4 V5 M6) D.3 Right Upper Extremity: 100%
A. Cerebral: Concious, coherent, oriented to three spheres of consciousness Left Upper Extremity: 100%
B. Cerebellar: (-) nystagmus, (-) tremors, normal gait Right Lower Extremity: 100%
C. Cranial Nerves: Left Lower Extremity: 100%
I. Olfactory- able to smell
II. Optic- 2-3 mm , equally reactive to light and accommodation E. Motor:
III, IV, VI. Occulomotor, Trochlear, Abducens- intact EOMs E.1 Right Upper Extremity: 5/5
V. Trigeminal- intact facial sensation; able to clench jaw E.2 Left Upper Extremity: 5/5
VII. Facial- (-) facial assymetry E.3 Right Lower Extremity: 5/5
VIII. Vestibulocochlear - able to hear E.4 Left Lower Extremity: 5/5
IX/X. Glossopharyngeal, Vagus-(+) gag reflex
XI. SpinalAccessory Nerve- able to shrug shoulders and turn head side to F. Deep Tendon Reflexes
side F.1 Right Biceps Reflex: +2
XII. Hypoglossal- able to protrude tongue (-) tongue deviation, (-)slurring F.2 Left Biceps Reflex: +2
of speech F.3 Right Patellar Reflex: +2
F.4 Left Patellar Reflex: +2
D. Sensory
D.1.Pain and Light Touch Sensation: intact G. Pathologic Reflexes:
D.2 Facial sensation over the skin supplied by V1, V2, V3 on both the right (-) Babinski (-) Kernigs sign
and left side of the (-) Clonus (-) Nuchal Rigidity
face: intact; no asymmetry

Name:

General Survey: The patient is awake, conscious, ambulatory, afebrile, and not in cardiopulmonary distress.
Head/Neck: No gross deformities; non-sunken eyeballs, anicteric sclerae, no eye discharges, pink palpebral conjunctiva; No ear pain/ discharge; No naso-oral discharges,
non-congested nasal turbinates; No neck masses
Lymph nodes: no cervical lymphadenopathies
LUNGS: Symmetyrical chest wall expansion, equal tactile fremitus, resonant, clear breath sounds
HEART: Adynamic precordium, no heaves/thrills, normal heart rate with regular rhythm, no murmurs, no extra heart sounds
Abdomen: Protuberant, Flabby, non-distended, no lesions, with normoactive bowel sounds, tympanitic, non-tender, no masses palpated
Not assessed
Skin: No lesions, no pallor, no jaundice, no cyanosis; warm to touch, with good skin turgor
Full and Equal peripheral pulses; no edema; good muscle tone and bulk; no limitation in range of motion
Genitalia:
Male: Tanner Stage __; normal, triangular distribution of hair; no lesions, no gross deformities, no discharges; non-tender
Female: Tanner Stage __; normal, inverted triangle distribution of hair; no lesions, no abnormal growth, no discharges; non-tender

NEUROLOGIC EXAMINATION

Glasgow Coma Scale 15 (E4 V5 M6) VIII. Vestibulocochlear - able to hear

A. Cerebral: Concious, coherent, oriented to three spheres of consciousness IX/X. Glossopharyngeal, Vagus-(+) gag reflex
B. Cerebellar: (-) nystagmus, (-) tremors, normal gait XI. SpinalAccessory Nerve- able to shrug shoulders and turn head side to
C. Cranial Nerves: side
I. Olfactory- able to smell XII. Hypoglossal- able to protrude tongue (-) tongue deviation, (-)slurring
II. Optic- 2-3 mm , equally reactive to light and accommodation of speech
III, IV, VI. Occulomotor, Trochlear, Abducens- intact EOMs
V. Trigeminal- intact facial sensation; able to clench jaw D. Sensory
VII. Facial- (-) facial assymetry D.1.Pain and Light Touch Sensation: intact
 D.2 Facial sensation over the skin supplied by V1, V2, V3 on both the right E.4 Left Lower Extremity: 5/5
and left side of the
face: intact; no asymmetry F. Deep Tendon Reflexes
D.3 Right Upper Extremity: 100% F.1 Right Biceps Reflex: +2
Left Upper Extremity: 100% F.2 Left Biceps Reflex: +2
Right Lower Extremity: 100% F.3 Right Patellar Reflex: +2
Left Lower Extremity: 100% F.4 Left Patellar Reflex: +2

E. Motor: G. Pathologic Reflexes:

E.1 Right Upper Extremity: 5/5 (-) Babinski (-) Kernigs sign
E.2 Left Upper Extremity: 5/5 (-) Clonus (-) Nuchal Rigidit
E.3 Right Lower Extremity: 5/5