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Help!! Can't Understand..she talks way tooo fast - Marlena


Posted: Oct 23, 2009

PHYSICAL EXAM

VITAL SIGNS: Blood pressure 112/80, weight is 155 lbs and height is 5'6"

GENERAL APPEARANCE: Is well developed, under no additional apparent distress.

HEART: Regular rate and rhythm, no murmurs.

NECK: Carotid, no bruits bilaterally orientation ___ are normal fundi with short disk margins

2 full visual fields greater at 346 ___ are intact, no nystagmus,

EYES: Pupils equal, round, reactive to light.

Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly, however on tandem walk she really has difficulty with that. She does not line up her toes easily, looses her balance very easily with that. Strength is 5 out of 5 got her up on more extremities, including proximal and distally. Tone is normal no clog wheeling. Detender reflexes are equal. Blanches are down going bilaterally. Coordination is slow but in tact on finger to nose bilaterally. She has no pronator drift however her left arm bobs quite a lot on out-stretched hands. Sensation has decreased on the right especially in her foot and hands as well.

DATA REVIEWED

I reviewed all the information that mentioned above from neuro spine and imaging.

Kind of late, but for future reference. - Hope this helps

[ In Reply To ..]

Just guessing on some of the blanks.  You might want to look at the following website. 


 http://medicaltranscriptionwordhelp.synthasite.com/physical-exam-words-and-phrases-for-mts.php


NECK: Carotid, no bruits bilaterally.


orientation ___ are normal fundi with short disk margins


2 full visual fields greater at 346 ___ are intact, no nystagmus,


           Fundi belong under eyes or HEENT: 


          (HEENT) Orientation (x3) (person, place and time) are normal. ???


          Fundi with sharp disk margins.


          ???


She does not line up her toes easily, looses her balance very easily with that. Strength is 5 out of 5 got her up on more extremities, including proximal and distally.


          loses her balance


          Strength is 5/5


Tone is normal no clog wheeling.


         normal, no cogwheeling.


Detender reflexes are equal.


          Deep tendon reflexes are equal


Blanches are down going bilaterally.


          Babinskis are downgoing bilaterally.   


Coordination is slow but in tact on finger to nose bilaterally.


          intact on finger-to-nose


She has no pronator drift however her left arm bobs quite a lot on out-stretched hands.


           outstretched


          arms ???


Sensation has decreased on the right especially in her foot and hands as well.


          Sensation is decreased …. hand (on the right – only 1 hand)


DATA REVIEWED


I reviewed all the information that mentioned above from neuro spine and imaging.


          At Tulsa NeuroSpine, we attempt to answer as many questions as possible about their problems, ... The diagnosis may require imaging studies, including x-rays, MRI scans, ... physical examination findings and the above mentioned studies.


 


 


 



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