CNS

Question 1

CNS: Normal

Answer 1

Alert and oriented x4. Normal strength and tone in all muscles. No gross focal, motor or sensory deficits. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.

CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal in upper and lower extremities. No pathologic reflexes.

Question 2

Vertigo

Answer 2

c/o dizziness x 1 week. usually when looking up (worse) or down
no ear pain
no tinnitus;
no assoc nausea, vomiting
no focal weakness
no f/c
no rhinorrhea
no visual changes
no chest pain
no SOB
no palpitation
similar symptoms in the past

Discussed diagnosis and treatment
Medication as prescribed
Red flag symptoms reviewed and management discussed