Motor - mild weakness and wasting in right forearm and hand intrinsic muscles

Tone - mild increased tone in right lower limb

Reflexes - 0 - 1+ right and left biceps, triceps , brachioradialis, 3+ knee and ankle, plantars - downgoing

Sensation - Decreased pinprick C4 to T4 bilaterally, anteriorly and posteriorly, vibration 256 - normal over distal upper and lower limbs

Coordination - Slight decrease finger nose and rapid alternating movement right upper limb

Gait - slightly spastic

Mental Status

Folstein

• Date 5/5
• Location 5/5
• Registration 3/3
• Recall 3/3
• Serial 7s 5/5
• Three Step Command 3/3
• Naming Two Objects 2/2
• Read and Obey 1/1
• Repetition 1/1
• Drawing 1/1
• Writing1/1

Cranial Nerve

I. Not tested
II. Visual acuity - 20/25 both eyes, fields - full, disc -sharp, pupils - equal and reactive direct and consensual
III, IV, VI. Normal to all 9 cardinal positions
V. Normal sensation to divisions 1,2,3, normal masseter, normal pterygoids, normal jaw jerk
VII. Normal facial movement
VIII. Normal hearing acuity, Weber - normal, Rhinne - positive
IX. Gag -normal, normal sensation from throat
X. Gag -normal, uvula midline
XI. Sternocleidomastoid - normal, trapezius - normal
XII. Tongue - midline