Primary Clinical Skills: Musculoskeletal/Neuro

Documentation Examples of Neuro (Separate Mental Status Example Below As Well):

Alert and oriented x 3   (A&O x 3)
Gait including heel to toe without abnormality noted
Romberg- maintains balance with eyes closed
Rapid alternating movements and finger-to -nose intact bilat.
No pronator drift
Visual acuity 20/20 right eye, 20/20 left eye (Note “with corrections” if appropriate.)
No papilledema or hemorrhage on fundoscopic exam.
No visual field deficits noted
Pupils equal, round, reactive to light (PERRL)
CN II-XII intact
Bilateral upper and lower extremities (BUE, BLE):                                              

• 5/5 strength
• 2+ reflexes including plantar response
• Pain, soft touch, position and vibration sense intact

1. Mental Status: Alert, oriented x3, and cooperative. Coherent thought processes. Cranial Nerves: I not tested, II-XII intact. Motor: Good muscle tone and bulk. Strength 5/5 in all major muscle groups. Cerebellar: Rapid alternating movements, finger-to-nose intact. Gait with normal base. Maintains balance during Romberg. No pronator drift. Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2+ throughout, downgoing plantar reflexes.
2. Mental Status: Alert, having difficulty finding words.  Cranial Nerves: I not tested, II-XII intact except testing of VII demonstrates right facial droop and flattening of right nasolabial fold. Motor: Good muscle tone and bulk. Strength 5/5 in all major muscle groups on left, but 3/5 in all major muscle on right. Cerebellar: Rapid alternating movements, finger-to-nose intact on left but unable to test on right due to weakness. Not able to test gait. Romberg not tested due to weakness. Right pronator drift present. Sensory: Decreased pinprick over right face, arm, and leg; intact on left. Reflexes:

Documentation Examples of MSK:

1. No gait abnormalities.  BUE and BLE examined:

-No asymmetry, redness, swelling, bruising, deformities, lesions, or masses.

-No tenderness to palpation of the muscles and joints.

-No tissue texture abnormalities.

-Full range of motion in all joints.

-Strength 5/5 throughout.

2. No gait abnormalities. Full ROM in all joints in BUE and BLE. Heberden nodes in DIP joints, Bouchard nodes in PIP joints of bilateral hands. Mild pain with flexion, extension, rotation of bilateral hips. Bilateral knees with moderate crepitus, no effusions present, bony enlargement along the tibiofemoral joint line. Bilateral feet with MTP joint hallux valgus deformities.

Documentation Examples of Mental Status:

1. Alert and oriented x 3, well-groomed, cheerful. Speech is fluent, clear words, coherent thought processes, good insight. Intact recent and remote memory and calculations with accurate serial 7s.
2. Oriented x 3. Appears sad and fatigued, not well-groomed. Speech is slow, mumbled words. Coherent thought processes with limited insight into current life reverses. Accurate digit span, serial 7s, and calculations with delayed responses. Good clock drawing.