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Neurological Evaluation
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Memory
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Speach
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Orientation
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Cranial Nerves
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Cerebellar Function
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Neuro: Normal Cerviacal
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Neuro: Abnormal
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Comment
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Neuro: Type of Altered
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Cervical DTR normal
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Bicep Reflex
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Brachioradialis reflex
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Tricep reflex
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Cervical Muscle Test Normal
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RUE Muscle weakness
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LUE Muscle weakness
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Neuro: normal
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Neuro: abnormal sensation
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Neuro: type of altered sensation
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Neuro Comments
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Normal DTR
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Patella reflex
• • •
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Achilles reflex
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Babinski sign
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Neuro: Normal muscle strength
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LLE weakness
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RLE Muscle weakness
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Medial Hamstring
• • •
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Orthopedic Eval
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Cervical
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Normal Ortho Tests
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Comments
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Positive ortho
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Comments
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Positive ortho
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Notes
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positive ortho
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Notes
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positive ortho
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Notes
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Decreased ROM with pain
• • •
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Normal ROM with pain
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Normal Rom
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Notes
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General notes
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Lumbar Exam
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Normal orthos
• • •
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Positive orthos
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Orthopedic Comments
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Positive ortho
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Note
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Positive ortho
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Note
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Positive ortho
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Note
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Positive Ortho
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Note
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Decreased ROM with pain
• • •
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Normal ROM with pain
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Normal ROM
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Toe Walk
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Heal Walk
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Gait
• • •
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Percussion
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Palpation
• • •
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Spasm
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Edema
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Upper Extremity Exam normal
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Abnormal Rt Shoulder
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Note
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Abnormal Lt Shoulder
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Note
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Abnormal Rt Elbow
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Note
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Abnormal Lt Elbow
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Note
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Abnormal Rt Wrist
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Note
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Abnormal Lt Wrist
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Note
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Positive Upper extremity Ortho
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Negative Ortho Tests
• • •
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Palpation
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Note
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Lower Extremity Exam Normal
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Abnormal Rt Hip
• • •
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Abnormal Lt Hip
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Abnormal Rt Knee
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Abnormal Lt Knee
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Abnormal Rt Ankle
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Abnormal Lt ankle
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Positive Lower extremity Ortho
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Negative Lower Extremity Ortho
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Note
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Anatomical Drawing Front
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Anatomical Drawing Back
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