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General WNL
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General Comments
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HEENT WNL
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HEENT Comments
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Skin WNL
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Well healed incision
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Skin Comments
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Cardiovascular WNL
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Cardiovascular Comments
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Lungs WNL
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Lungs Comments
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Abdomen WNL
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Abdomen Comments
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Pulses - normal
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Pulses Abnormal
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MSK WNL
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MSK Comments
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Cervical Exam - Normal
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Cervical spine freewrite
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Cervical Spine Comments
• • •
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Lumbar Spine - Normal
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Lumbar spine freewrite
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Lumbar Spine Comments
• • •
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Neurologic Exam Normal- Upper Ext
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Neuro Exam Normal- Lower ext
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Neurologic Exam - As Listed Below
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Neuro Exam comments
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Right Deltoid Grade
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Left Deltoid Grade
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Right Biceps Grade (elbow flex)
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Left Biceps Grade (elbow flex)
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Right Triceps Grade (elbow ext)
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Left Triceps Grade (elbow ext)
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Right Wrist Extensor Grade
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Left Wrist Extensor Grade
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RIght Wrist Flexor Grade
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Left Wrist Flexor Grade
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Right Grip Grade
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Left Grip Grade
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Right Intrinsics Grade
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Left Intrinsics Grade
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Right Iliopsoas Grade (hip flex)
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Left Iliopsoas Grade (hip flex)
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Right Hamstring Grade (knee flex)
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Left Hamstring Grade (hip flex)
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Right Quadriceps Grade (knee ext)
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Left Quadriceps Grade (knee ext)
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Right Tibialis Anterior Grade (dorsi)
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Left Tibialis Anterior Grade (dorsi)
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Right EHL Grade (toe dorsi)
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Left EHL Grade (toe dorsi)
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Right Gastrocnemius Grade (plantar)
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Left Gastrocnemius Grade (plantar)
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Right Peroneal Grade (foot eversion)
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Left Peroneal Grade (foot eversion)
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Reflexes normal
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Reflexes Abnormal bilateral
• • •
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Reflexes listed below
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Right biceps
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Left Biceps
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Right brachioradialis
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Left brachioradialis
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Right triceps
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Left triceps
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Right quadriceps
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Left quadriceps
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Right patellar
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Left patellar
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Right ankle
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Left ankle
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Right achilles
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Left achilles
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Coordination-Normal
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Gait normal
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Gait Abnormal
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Gait comments
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Sensory Exam normal
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Sensory Exam As Indicated Below
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Sensory Exam comments
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Sensory Exam RUE
• • •
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Sensory Exam LUE
• • •
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Sensory Exam RLE
• • •
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Sensory Exam LLE
• • •
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Peripheral Nerve Signs
• • •
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Radicular Signs
• • •
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Myelopathic Signs
• • •
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Straight Leg Raise Positive
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OTHER pertinent exam findings
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Imaging
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XR
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CT Scan
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MRI
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Labs/Other Studies
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Imaging Reviewed
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