学习神经系统检查(英文版)

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Neurological Examination
MENTAL STATUS: The patient was oriented fully to person and time, but not to place. He named the city and state, but not the county, hospital or floor of the hospital. Folstein Mini-Mental Status examination score was 25 of 30. He missed one point for word recall, one for the copying diagram task and one for a sentence writing task. He had good repetition and registration, but great difficulty with proverb interpretation and sentence writing. He exhibited slowing of speech production.
CRANIAL NERVES:
I: Not tested
II: Visual acuity was 20/20 bilaterally, without visual field deficits identified by confrontation testing. Funduscopic examination revealed sharp disc margins bilaterally. Cotton-wool spots were visible in both fundi, more pronounced on the left.
III, IV, and VI: Extraocular movements were full without nystagmus. The patient did not exhibit ptosis.
V: Sensation was intact in all sensory distributions of the trigeminal nerve. Strength of muscles of mastication was normal.
VII: Strength of facial musculature was intact bilaterally. Taste sensation was normal in the anterior two-thirds of his tongue.
VIII: Hearing was markedly decreased in the right ear to whisper and finger rubs. Reporting on Weber testing was inconsistent.
IX, X: Gag reflex was normal, with normal sensation at the palate. Palate elevates at midline.
XI: Sternocleidomastoid and trapezius strength normal bilaterally.
XII: Tongue protruded in the midline without atrophy or fibrillations.
MOTOR EXAMINATION: The patient demonstrated normal bulk and tone in all four limbs. He had 5/5 strength in all four limbs.
SENSORY EXAMINATION: Sensory examination was intact to fine touch, proprioception, vibration, temperature, pinprick, and pain in all four limbs.
REFLEXES: He exhibited very brisk, 3+ reflexes with spread at biceps, triceps and brachioradialis on both sides. Reflexes were slightly more brisk but still 3+ at both knees. The right Achilles reflex was 4+ with four beats of non-sustained clonus at the right ankle. The left Achilles reflex was 3+. Plantar responses were flexor bilaterally.
COORDINATION: He exhibited truncal ataxia with titubation. He had dysmetria with finger-nose-finger and heel to shin testing bilaterally. The rate and accuracy of rapid alternating movements was decreased bilaterally.
GAIT: He exhibited a wide-based and ataxic gait, and tended to fall to the right.
不知在春节前有没加分呀