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220 Neuro/mental status

Terms in this set (62)

S: No past hx. of surgeries, stroke, seizures, alcoholism, drug use, or meningitis. Family hx. unremarkable. Denies frequent or severe H/A's, dizziness, or vertigo. Denies tremors, weakness, numbness, tingling, difficulty swallowing, or speaking. Reports no work or leisure hazards.
O: Erect posture, body movements smooth & purposeful, dress appropriate to the season, hygiene clean, alert with pleasant facial expression, speech clear & understandable, cooperative mood, oriented X 3, good attention span, recent & remote memory intact, logical thought processes, with good judgment and insight ability.
O: Erect posture, body movements smooth & purposeful, dress appropriate to the season, hygiene clean, alert with pleasant facial expression, speech clear & understandable, cooperative mood, oriented X 3, good attention span, recent & remote memory intact, logical thought processes, with good judgment and insight ability.
O: CN I intact AEB identifies correct scents, CN II, III, IV, VI intact AEB reads small print, PERRLA, EOM's intact, no ptosis or nystagmus. CN V intact AEB facial sensation = bilaterally, jaw strength = bilaterally. CN VII intact AEB facial muscles intact & symmetric. CN VIII intact AEB normal hearing. CN IX & X intact AEB uvula rises on phonation, swallow reflex present. CN XI intact AEB shoulder shrug & head movement intact & = bilaterally. CN XII intact AEB tongue protrudes midline.

No atrophy, tremors, weakness; full ROM of all extremities. Gait & tandem walk normal. Negative Romberg test. Performs repetitive alternating movements. Skin sensation intact at all dermatome levels. Vibratory sensation, stereognosis, & graphesthesia intact. Reflexes 2+ bilaterally. Negative Babinski sign. No ankle clonus.