Neuro Normal Exam

General: awake and alert. 
Head: atraumatic.
Ears: No drainage, Mouth: Oral mucuse is pink and moist.
Eyes: No drainage or hemorrhage. Optic disks sharp.
Cardiovascular: no bruits, heart S1 S2 regular.
Lungs: clear to ausculation.
Abdomen: soft, nontender without guarding.
Extremities: Peripheral pulses are present and normal.

Mental Status
Orientation: AAO x[textarea name="variable_1" default="3"]


Cranial Nerves (CN)
CN II: visual fields were full to confrontation
CN III,IV,VI: extraocular muscles grossly intact. Pupils were equal, round, and reacted from 3 mm to 2 mm to light
CN VIII: hearing was grossly normal.
CN IX,XII: palate elevation and tongue movements were symmetrical.

Motor (including CN VII, XI):
There was no facial droop or flattening of the nasolabial fold, the shoulder shrug was symmetric, and there was no pronator drift.

Motor: Grossly normal ROM in all four extremities
Muscle tone and bulk: normal in all four extremities and there was no spasticity, rigidity, or cogwheeling.

Reflexes: 
2+ in the uppers and lowers. No UMN signs.

Sensory:
light touch was symmetric on the face (CN V), trunk, and extremities.

Coordination: 
Normal finger/nose and heel/knee/shin tests.

Gait:
deferred

GCS 
Eye Opening
Spontaneous (4)
To sound (3)
To pressure (2)
None (1)

Verbal Respones
Orientated (5)
Confused (4)
Words (3)
Sounds (2)
None (1)

Motor Response
Obeys commands (6)
Localise to pain(5)
Normal flexion (4)
Abnormal flexion(3)
Extension (2)
None (1)

General: awake and alert.
Head: atraumatic.
Ears: No drainage, Mouth: Oral mucuse is pink and moist.
Eyes: No drainage or hemorrhage. Optic disks sharp.
Cardiovascular: no bruits, heart S1 S2 regular.
Lungs: clear to ausculation.
Abdomen: soft, nontender without guarding.
Extremities: Peripheral pulses are present and normal.

Mental Status
Orientation: AAO x



Cranial Nerves (CN)
CN II: visual fields were full to confrontation
CN III,IV,VI: extraocular muscles grossly intact. Pupils were equal, round, and reacted from 3 mm to 2 mm to light
CN VIII: hearing was grossly normal.
CN IX,XII: palate elevation and tongue movements were symmetrical.

Motor (including CN VII, XI):
There was no facial droop or flattening of the nasolabial fold, the shoulder shrug was symmetric, and there was no pronator drift.

Motor: Grossly normal ROM in all four extremities
Muscle tone and bulk: normal in all four extremities and there was no spasticity, rigidity, or cogwheeling.

Reflexes:
2+ in the uppers and lowers. No UMN signs.

Sensory:
light touch was symmetric on the face (CN V), trunk, and extremities.

Coordination:
Normal finger/nose and heel/knee/shin tests.

Gait:
deferred

GCS
Eye Opening
Spontaneous (4)
To sound (3)
To pressure (2)
None (1)

Verbal Respones
Orientated (5)
Confused (4)
Words (3)
Sounds (2)
None (1)

Motor Response
Obeys commands (6)
Localise to pain(5)
Normal flexion (4)
Abnormal flexion(3)
Extension (2)
None (1)

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 1 form elements, 213 boilerplate words, 1 text areas, 1 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: