CNS physical exam, cranial nerve???, motor, cerebellum??? and sensory were normal...thanks.ASAP
Posted By: MT_gurl on 2009-02-07
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Subject: CNS physical exam, cranial nerve???, motor, cerebellum??? and sensory were normal...thanks.ASAP
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Under cranial nerve exam
Subject: Under cranial nerve exam
PERRL with left exophoria. Mild left S/L: LI-TOE-SIS or LID-TOE-SIS (chronic)
My expander is changing it to lithosis but I cannot find it!!??
TIA.
on cranial nerve exam, doc clearly says "equal
Subject: on cranial nerve exam, doc clearly says "equal
ocular motion is intact" - I'm assuming she made a mistake, but want to verify that this isn't a valid term - "equal ocular" ??
Ok, brain overload, cranial nerve exam...sm
Subject: Ok, brain overload, cranial nerve exam...sm
Normal eye movement. Face is symmetric. Normal facial sensation. Tongue and palate are in the midline. Negative s/l "paulpeck" maneuvers.
Motor Exam: s/l diminished tone, normal (sm)
Subject: Motor Exam: s/l diminished tone, normal (sm)
no atrophy.
the patient had a stroke and has no residual except for dysarthria. Can a motor exam show diminished tone and still be considered normal?
Physical exam: Head is normalized normal.
Subject: Physical exam: Head is normalized normal.
Just a well-child check, no special diagnosis or medical history.
NEURO - Cranial nerve II exam - s/l 'free clots' or 'free cuts' sm
Subject: NEURO - Cranial nerve II exam - s/l 'free clots' or 'free cuts' sm
Fundi with no hemorhages. Visual acuity 20/70 bilaterally. There were no 'free clots.' Cranial nerves III, IV, and VI...
tia
Motor-sensory question
would this transcribed as Motor-sensory: 5/5 or as a clipped sentence Motor-sensory 5/5.
Under the physical examination
Clipped sentence. Motor/sensory 5/5. nm
Subject: Clipped sentence. Motor/sensory 5/5. nm
s
motor and sensory s/l mentality intact
Subject: motor and sensory s/l mentality intact
sensory (as in sensory nerve)
Subject: sensory (as in sensory nerve)
I found a Bromage scale used for nerve/motor blocks. Maybe that's it.
Subject: I found a Bromage scale used for nerve/motor blocks. Maybe that's it.
Description of the Bromage score
Grade |
Criteria |
Degree of block |
I |
Free movement of legs and feet |
Nil (0%) |
II |
Just able to flex knees with free movement of feet |
Partial (33%) |
III |
Unable to flex knees, but with free movement of feet |
Almost complete (66%) |
IV |
Unable to move legs or feet |
Complete (100%) |
cranial nerve palsy
Subject: cranial nerve palsy
with "E stem" to the face?? Thanks!
I don't think there is a cranial nerve XIIII?
Subject: I don't think there is a cranial nerve XIIII?
did you mean cranial nerve VIII?
Motor nerve study with "lace" dependent pattern. see message plz :)
Subject: Motor nerve study with "lace" dependent pattern. see message plz :)
Motor nerve conduction studies were notable for decreased amplitude in both upper and lower extremities in a lace dependent pattern.
intact cranial NERVE function?
Subject: intact cranial NERVE function?
never heard that. Possibly cranial nerve II through XII ????
Subject: never heard that. Possibly cranial nerve II through XII ????
xx
found cranial nerve toxicity... nm
Subject: found cranial nerve toxicity... nm
5/5 sounds like normal motor strength...but sm
Subject: 5/5 sounds like normal motor strength...but sm
...i have no idea about your s/l... "overall motor strength"? there's also an OMA score (or OMAS)=Olerud & Molander Ankle Score but 5/5 power doesn't match that...?? =(
Pt to physical therapy for presumed "saracalgia" and possible mild sensory radicular signs. sm
Subject: Pt to physical therapy for presumed "saracalgia" and possible mild sensory radicular signs. sm
The only other neurological complaint that he has had is some low-grade headache at the base of his skull in the left side of his neck that sometimes radiates to his shoulder, which has been going on since November. He is going to physical therapy for presumed saracalgia and possible mild sensory radicular signs.
cranial nerve 3,4,6 S Drives and Lobins are intact?
Subject: cranial nerve 3,4,6 S Drives and Lobins are intact?
I got the
cranial nerves 3,4,6 ??S S-drives and Lowbins? are intact?? Any ideas?
denervated *frontentials* seen with normal motor unit potentials.(EMG) Thanks. nm
Subject: denervated *frontentials* seen with normal motor unit potentials.(EMG) Thanks. nm
nm
Sensory exam
Subject: Sensory exam
Thinking about the first one.
Neck dissection - s/l venicomatants were left in place covering the 12th cranial nerve. TIA
Subject: Neck dissection - s/l venicomatants were left in place covering the 12th cranial nerve. TIA
x
position sense - as in sensory exam (I think) (NM)
Subject: position sense - as in sensory exam (I think) (NM)
x
DTRs were dictated in sensory exam. Thanks for your help! Still stumped!
Subject: DTRs were dictated in sensory exam. Thanks for your help! Still stumped!
Neuro doc under sensory exam says s/l staring nosia's intact. TIA!!!
Subject: Neuro doc under sensory exam says s/l staring nosia's intact. TIA!!!
Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
Subject: Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
Throat exam is normal, as were the rest of her neck, face, and skull exam.
Subject: Throat exam is normal, as were the rest of her neck, face, and skull exam.
nerve conduction study shows s/l speed ? reduction to 1/3 of normal.
Subject: nerve conduction study shows s/l speed ? reduction to 1/3 of normal.
I would type cranial nerve VII.....blah, blah
Subject: I would type cranial nerve VII.....blah, blah
NM
The only other s/l mammalian is a slight pectus excavatum, otherwise normal physical examination.
Subject: The only other s/l mammalian is a slight pectus excavatum, otherwise normal physical examination.
x
Facial nerve exam...
Subject: Facial nerve exam...
sentence: The patient's facial nerve exam is significant for a 'haus brock en' 5 of 6.
Physical exam
Subject: Physical exam
Height: Six feet.
I'm having trouble remembering all my rules on numbers for stats and such. Is this right? Thank you.
On physical exam.. S/L
Subject: On physical exam.. S/L
or maybe slight disks bilaterally? I'm drawing a blank... HELP PLEASE and THNX!
Physical exam
Subject: Physical exam
The doctor dictated "no jugular venous distension at 30 degrees" under heart of the physical exam. Shouldn't it go under neck? Thank you.
physical exam-GU
Subject: physical exam-GU
obese 9 year old--phallus difficult to examine as the patient has a large sl-paptha- and has a concealed phallus.
re physical exam
Subject: re physical exam
PHYSICAL EXAMINATION: Significant findings for left lower quadrant tenderness. Blood pressure was 124/78, pulse rate of 96, and respiratory rate of 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.
I would type it this way or at least make it present tense. On my accounts, I am required to categorize these things.
PHYSICAL EXAMINATION:
Abdomen: Significant findings for left lower quadrant tenderness. Vital signs: Blood pressure 124/78, pulse rate 96, respiratory rate 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.
GI physical exam
Subject: GI physical exam
In the physical exam, s/l thenar and epithilial wasting. He is listing liver disease stigmata and I just blanked out on this. Help!
This is on physical exam
Subject: This is on physical exam
thanks for trying.
physical exam help
Subject: physical exam help
Physical exam, under Extremities, doctor states ___ pulses throughout.
It sounds like temporis pulses. I know of temporal pulses, but would that be throughout the extremities? Thank you!
Physical exam help?
Subject: Physical exam help?
EXAMINATION: No costovertebral angle tenderness. Abdomen has normal active bowel sounds in all quadrants. It is supple. Extremely tender left upper quadrant and going down not quite into the groin. Difficult to check the (s/l sternal) border because of increased tenderness but the spleen may be mildly enlarged but no distinct masses felt. I am unable to check for rebound or guarding because she is so exquisitely tender with even a very light touch.
ASSESSMENT: Acute left upper quadrant pain.
s/l sternal border? Any help would be great?
physical exam
Subject: physical exam
Probably just means + (the plus sign), as in positive S1, S2...just means he heard 1st and 2nd heart sounds clearly (as opposed to sounds to distant or obscured by extra sounds). If something was dictated before that, I would put a comma and use the plus sign, i.e., PREVIOUS TEXT, + S1, S2. If nothing precedes it, I would type positive S1, S2. If account wants verbatim, give it to them.
It was just a physical exam, and I don't know
Subject: It was just a physical exam, and I don't know
However, I do think it was "cervical or" inguinal adenopathy. This guy is a real mush mouth. THANK YOU ALL SO MUCH FOR YOUR HELP! I am sorry I wasn't clear enough earlier in my first message. I really do appreciate your help. This is a great board to come to--everyone is so knowledgeable!
Need help with physical exam please
Subject: Need help with physical exam please
I am wondering if, in the last sentence, where "drop can arc" is dictated . . . would she be referring to three tests/maneuvers such as Drop Arm, Empty Can, and an Arc test, or is it correct as is?
She has excellent range of motion of the shoulder. Good grip strength. Distal pulses and sensation are intact. She can do a full drop can arc.
TIA
Please help with physical exam (sm)
Subject: Please help with physical exam (sm)
Over the central aspect of the wound there is s/l shelfing of the superior aspect of the skin
Physical exam help.....
Subject: Physical exam help.....
The calf was nontender. The lower leg was s/l nonpeeing. Nonpitting? Not pitting? Help, please!
Physical exam help
Subject: Physical exam help
HEENT: It sounds like she is saying 'TO' mucosa pink and moist. Or TL mucosa.
Any ideas?
Under physical exam...
Subject: Under physical exam...
I know this is probably really easy...BUT, the doc is rattling it off and he's new to me...
ABDOMEN: Soft, nontender, nondistended, ___ to bowel sounds.
Is it normal to bowel sounds?
Thanks....
Physical Exam
Subject: Physical Exam
s/l duprichen contractions of both hands
Physical exam
Subject: Physical exam
New acct. Dr. states: Lungs were congested with s/l "rasmus" Any ideas? Thanks for the help.
physical exam
Subject: physical exam
thanks ss. Unfortunately, not rales or rhonchi. He dictates that quite often and it sounds nothing like it! I might be stuck on this one.
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