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


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
Sternocleidomastoid - normal, trapezius - normal
Tongue - midline