General Appearance: ***alert, NAD/mildly uncomfortable/uncomfortable/photophobic***.
Eyes: ***PERRLA/fundi normal/EOMI***
HENT: ***ears normal/pharynx normal***
Neck: ***supple/nuchal rigidity***
Heart: ***RR, normal S1 and S2, no murmur***
Lungs: ***clear/decreased breath sounds***
Neuro:
Cranial nerves: ***normal/2-12 intact***
Reflexes: ***normal, symmetric/symmetric hyperreflexic DTRs/symmetric hyporeflexic DTRs/symmetrically decreased ankle reflexes/no Babinski***
Strength: ***normal and symmetric/decreased left upper extremity/decreased right upper extremity/decreased left lower extremity/decreased right lower extremity***
Cerebellar function tests: ***Romberg normal/finger to nose normal/tandem walking normal***
loading...
Share this Soapnote





You must log in to post a comment.