NORMAL SYSTEMIC PHYSICAL EXAMINATION
Vital signs as follows: BP HR RR Temp sats
General: awake, not in distress
Heart: normal S1 S2, no MRG, NRRR, peripheral pulses 2+ bilaterally, no edema
Lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi, no accessory muscle use
Abdomen: soft, nontender, nondistended, bowel sounds normal, no palpable masses
NORMAL NEURO DICTATION
Mental Status, patient is awake, alert, oriented to person place and time, normal affect; Attention, can spell WORLD backwards, good attention span; speech is fluent without paraphasic errors, able to repeat, name objects, read and write; memory is good, calculation is good, no left-right confusion; Praxis: able to mimic blowing out match with either hand.
Cranial nerve exam: II, III pupils equal and briskly reactive to light; visual acuity, visual fields full by confrontation, III IV VI EOM intact without nystagmus, no ptosis; V sensation intact to light touch, masseters strong symmetrically, VII face symmetric without weakness; VIII hearing grossly intact; IX X palate elevates symmetrically XI good shrug XII tongue protrudes midline, no atrophy or fasciculation.
DTRs: normoreflexive – bilateral biceps, brachioradialis, patellar and Achilles reflexes
MMT, strength is 5/5 on all 4s. Sensory testing intact to light touch, pinprick, temperature, vibration and joint position intact. No evidence of extinction. Coordination: able to do rapid alt and point-to-point movements.
Gait posture, stance, stride and arm swing normal.
CORE MEASURES:
NIHSS in ED
If no tPA given, why?
If Afib – on AC? If no AC, reason / plan
Meds listed out
Lipid panel, A1C Carotids (Doppler, CTA, angio), Echo
On statin, if not, why?
ASA & PLavix
PT/OT, if no PT/OT why?
Modified Rankin Scale
