Table 2. Example of relevant physical data included on the case presentation.
| Physical exam information | Case #1 |
|---|---|
| General | Well developed, well nourished |
| Orientation | Oriented to time, place and person |
| Peripheral vascular exam | Normal |
| Facial sensation | Intact |
| Tongue | Midline |
| Uvula/shoulder shrug | Elevates symmetrically |
| Abdomen | Soft, non-tender, non-distended |
| Cervical ROM | Normal, without pain |
| Spurling exam | Negative bilaterally |
| Spine | Pain with forward flexion, extension and lateral flexion. Increased thoracic kyphosis with standing |
| Upper extremity motor, sensory and reflexes | Normal |
| Lower extremity motor, sensory and reflexes | Motor: normal; sensory/reflexes: normal; toe response: equivocal; straight leg raise: negative; Romberg: negative |
ROM, range of motion.