GA: NAD

VS: WNL

HEENT: NC/AT, no conjunctival pallor/redness, EOMI without diplopia and lid lag, PERRLA, no
nystagmus, no papilledema, red reflex seen, no hemorrhages/exudates, no AV nicking, no
neovascularization, no retinal detachment. Visual acuity normal/decreased; visual fields intact L. R Visual
field deficit. No nasal congestion/discharge. Mouth is moist, no oral lesions, no tonsillar
erythema/exudate/enlargement. No tenderness of auricle or peri auricle, no LAD, no redness of ear
canal, no discharge, no cerumen, TM with light reflex. AC>BC bilaterally, Weber with no lateralization,
hearing grossly intact, finger rub heard bilaterally.

NECK: Supple, no thyromegaly, no LAD, no JVD

CVS: No JVD, no carotid bruits. RRR, S1/S2 WNL, no murmurs, gallops or rubs. PMI not displaced.
Peripheral pulses regular bilaterally, no cyanosis, clubbing. No peripheral edema

LUNGS: No gross abnormalities, no tenderness to palpation, resonant, tactile fremitus WNL, normal
chest expansion, normal vesicular breath sounds bilaterally, no rales, wheeze, rhonchi or rubs.

ABD: No gross abnormalities. Soft, non-distended, no rigidity/guarding, tender in RUQ, normal tympanic
percussion note, BS +ve,no bruits, no masses/organomegaly +ve Murphy’s ,no rebound tenderness, -ve
Roving, -ve psoas, -ve obturator, -ve CVA tenderness

NEURO: MMSE: AAO x 3. UPPER EXT: motor – 5/5 b/l. Sensory: sensation intact to
dull/sharp/position/vibration b/l DTR: hyper/hypo/2+ reflexes bilaterally. Pulses regular b/l. LOWER EXT:
motor – 5/5 bilaterally. Sensory: Diminshed pinprick on plantar surface b/l. sensation intact to soft
touch/position/vibration bilaterally DTR: ankle and knee reflexes intact b/l, Babinski -ve. Pulses regular
b/l. GAIT – normal/atalgic. CEREBELLUM: -ve Romberg, normal rapid alternating movements(no
dysdiadochokinesia) , heel to shin test normal.

MMSE: AAO x 3, recall 3/3, distant memory intact, command 3/3, attention + concentration intact (can
spell backwards) judgement intact. Co-operative, no hostile behavior. normal speech.

PSYCH: AAO in person and place, disoriented in time, recall 3/3 distant memory intact, command 3/3,
attention + concentration intact (can spell backwards) judgement intact(not intact). Co-operative, no
hostile behavior. Normal speech/ Speech is pressured (fluent/hyperverbal/speaks
slowly/stutter/normal). Patient appears disheveled (well-groomed/dirty clothes/anxious/restless) Mood
is dysphoric(unsatisfied) (anxious/depressed/angry/euphoric/sad/irritable) Affect is consistent with
mood. Thought process is rational(irrational). (Denis) Abnormal perceptions(+ve hallucinations/believes
is in danger etc…..) No suicidal/homicidal ideations

ALZH: NEURO - AAOx3, recall 3/3 distant memory not intact. Command 3/3. Attention+concentration
intact(can spell backwards) judgment is intact. pt is co-operative, not hostile, speech is pressured. CN 2-
12 grossly intact. Motor 5/5 in all muscle groups. DTRs hyperreflexia in L upper and lower extremity and
hyporeflexia in R. Babinski +ve b/l. Gait is normal. Sensations intact to pinprick and soft touch.
THYROID: No lid lag. No tremor/palmar sweating/nail changes/hair loss. No proximal msl weakness.DTR
normal bilaterally, no edema.

LIVER: no conjunctival pallor/scleral icterus . ABD- no striae, telangiectasia, spider nevi. BS +ve, no
hepatic bruit. No tenderness, -ve murphy’s, no hepatosplenomegaly, no fluid thrill. EXT - No asterexis,
no peripheral edema. SKIN- jaundice, excoriations due to scratching, no palmar erythema, no spider
telengectasia.

MIGRAINE/NECK PAIN: MMSE. HEENT. CN2-12 grossly intact. NECK – No

tenderness/warmth/erythema/swelling/deformity. No tenderness. No stiffness, ROM – normal,
Spurling/kurnigs/Brudzinski/Lhermitte – WNL. UPPER LIMB: NEURO

EXTREMETIES: no gross abnormality. No edema/cyanosis/clubbing. Peripheral pulses 2+ symmetric.

PAD: no hair loss/shiny tight skin/hypertrophic nails. Sensations intact.

TREMOR: Pt is sitting comfortably with right hand shaking and bead rolling. No head nodding. No limited
facial expressions, no drooling. Upper ext rigidity but no cogwheeling. Stooped posture, shuffling gait,
turns in block.

CTS: HANDS - no swelling/erythema/atrophy/deformity/scars bilaterally. ROM – normal bilaterally.

Power 5/5 bilaterally. Sensations intact in L and decreased in R 4th and 5th digits. Phalen and Tinel test -
ve on L and +ve on R side. -ve Finkelstein

JOINT: no gross abnormalities. No tenderness/redness/warm/crepitus on palpation, no swelling. ROM –

normal. GAIT – normal/antalgic. KNEE- anterior/posterior drawer, mc murray. WRIST-Tinel, Phalen,
Finkelstein. ELBOW- Cozen, medial epicondylitis. HIP – Only ROM. BACK – SLR +ve/-ve

BACK PAIN: GAIT – normal. No scar/erythema/deformity/swelling. No tenderness to palpation. ROM-

normal. Straight leg test +ve/-ve. LOWER EXT: Motor 5/5. Sensations intact. DTRs 2+ symmetric. Pulses
2+ symmetric. Babinski -ve

ANKLE PAIN: GAIT- antalgic gait. No scar/erythema/deformity/atrophy/swelling. No tenderness and

crepitus around ankle joint and bones. Motor 5/5 in R and decreased in L foot. Sensations intact
bilaterally. Palpate knee

SHOULDER PAIN: Both shoulders symmetrical no gross abnormalities. No

tenderness/erythema/deformity/warmth/crepitus/swelling. ROM- normal. Motor 5/5. Sensation intact.
Pulses 2+. Painful arc/drop arm/neer/Hawkins -ve. Palpate elbow and cervical spine

ELBOW PAIN: no gross abnormalities. No tenderness/erythema/deformity/warmth/crepitus/swelling.

ROM (flexion/extension/pronation/supination) – normal. Motor 5/5. Sensation intact. Pulses 2+. LAT
EPI : Cozen test. MEDIAL EPI: Medial epicondylitis test.

HIP PAIN: GAIT – normal. LOWER EXT: Motor 5/5. Sensations intact. DTRs 2+ symmetric. Pulses 2+
symmetric. Babinski -ve

KNEE PAIN: no gross abnormalities. No tenderness/erythema/deformity/warmth/crepitus/swelling.

ROM-Normal. Motor 5/5. Ant drawer/Post drawer/McMurray’s test -ve bilaterally.