PE findings

Question 1

HEENT:

Answer 1

Head: Atraumatic, normocephalic
Eyes: EOMI, PERRLA, normal eye fundus.Nose: No nasal congestion.
Throat: No tonsillar erythema, exudates, or enlargement.
Mouth: Moist mucous membranes, good dentition, no lesions.

Question 2

Neck:

Answer 2

Supple, no JVD, normal thyroid, no cervical LAD.

Question 3

Nervous System:

Answer 3

Mental status: Alert and oriented x 3, good concentration.
Cranial nerves II–XII grossly intact.
Motor: Strength 5/5 in all muscle groups.
DTRs: 2+ intact and symmetric, Babinski

Question 4

Chest/Lung:

Answer 4

Clear to percussion bilaterally.
No rales, rhonchi, wheezing, or rubs.
No tenderness to palpation.
Tactile fremitus WNL.

Question 5

Heart:

Answer 5

PMI not displaced.
Regular rate and rhythm.
Normal S1, S2.
No murmurs, rubs, or gallops.

Question 6

Abdomen:

Answer 6

Soft, nontender, nondistended, BS

no hepatosplenomegaly.

Question 7

Extremities:

Answer 7

No clubbing, cyanosis, or edema.

Question 8

Mental Status Exam:

Answer 8

Patient speaks slowly.
No hostile behavior toward the interviewer.
Blunt affect with poor eye contact.
Inattentive to interviewer.
3/3 registration, 3/3 recall at 3 times.
Distant memories are impaired.
Oriented to person, date, and place.
Completed three-step command.
Right-handed.
1/5 on serial 7s.
Poor judgment.

Question 9

Diagnostic CBC

Answer 9

To look for leukocytosis, a nonspecific sign of infection or inflammation. Mild normocytic anemia and thrombocytosis may also be seen in temporal arteritis.

Question 10

Diagnostic CT—head or MRI—brain:

Answer 10

Headache syndromes are largely clinical diagnoses. Neuroimaging is generally reserved for patients with acute severe headache, chronic unexplained headache, or abnormalities on neurologic exam. MRI provides greater anatomic detail, but CT is preferred to rule out acute bleeds.

Question 11

Diagnostic LP

Answer 11

To look for elevated opening pressure in pseudotumor. CSF is otherwise normal. RBCs and xanthochromia can be seen in subarachnoid hemorrhage (perform if suspicion is high despite a negative CT scan).

Question 12

Diagnostic CT—sinus:

Answer 12

To look for sinusitis.

Question 13

CN I

Answer 13

intact smell

Question 14

CN II

Answer 14

visual acuity 20/20. No visual field defects. Ocular fund normal cup to disc ratio

Question 15

CN III, IV, VI

Answer 15

EOMI,

Pupils equally round & reactive to light & accommodation

Question 16

CN V

Answer 16

normal sensation of face

normal mastication

Question 17

CN VII

Answer 17

normal motor function of face above & below eyes

Question 18

CN VIII

Answer 18

normal hearing acuity in one or both ears
Rinne- AC > BC
Weber- No lateralization

Question 19

CN IX & X

Answer 19

symmetric elevation of soft palate

Question 20

CN XI

Answer 20

normal head, neck & shoulder muscle strength bilaterally

Question 21

CN XII

Answer 21

normal tongue movements

Question 22

Motor strength

Answer 22

5/5 in areas tested

Question 23

DTR

Answer 23

2+ in biceps, triceps, brachioradialis, patellar, achilles bilaterally
neg Babinski

Question 24

Sensation

Answer 24

intact

Question 25

Cerebellar

Answer 25

normal finger to nose, heel to knee, rapid movements, negative Romberg, no pronator drift, gait intact

Question 26

Folstein MMSE

Answer 26

25/30