neurological exam documentation template is a neurological exam documentation template sample that gives infomration on neurological exam documentation template doc. When designing neurological exam documentation template, it is important to consider different neurological exam documentation template format such as neurological exam documentation template word, neurological exam documentation template excel. You may add related information such as neuro exam template pdf, neuro exam cheat sheet, full neurological examination pdf, neurological examination checklist.
neurological exam documentation template
the patient is a 50-year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago. she rates the pain as 7 or 8 on a scale of 1 to 10, with 10 being the worst possible headache. she is not aware of a change in her appearance, but her husband notes that her right eye seems to protrude; he thinks that this is a change in the last few days. her maternal grandfather had a stroke at age 69. there is no other family history of stroke or vascular disease, but she has no information about her father’s side of the family. mental status: the patient is alert, attentive, and oriented. when the patient is looking to the left, the right eye does not adduct.
there is ptosis of the right eye. tandem gait is normal when the patient closes one of her eyes. ophthalmoplegic migraine remains a likely diagnosis given the history of migraine with aura, even though the current headache is different in character from her usual headaches and is not associated with visual aura, nausea/vomiting, or photophobia. so the fact that her pupil is normal in size and reactive to light weighs against the diagnosis of a compressive lesion such as an aneurysm or tumor, but does not eliminate the possibility. the patient denies a history of hypertension, is not currently hypertensive, and has no risk factors for vascular disease, but the possibility of a genetic disorder such as cadasil cannot be excluded given the lack of paternal history. if the cerebral angiogram and lumbar puncture are negative and her headache does not improve, she may be a candidate for iv dihydroergotamine treatment.
she denies previous episodes of transient or permanent visual or neurologic changes fundoscopic exam is normal with sharp discs and no vascular changes. in practice, the neurological exam is tailored to the patient’s about it for as long as you will listen), i will include at the end of this document a. notes for neurological exam templates: although billing is not required for residents, it is a good habit for senior residents to learn and follow the correct billing , neuro exam template pdf, neuro exam template pdf, neuro exam cheat sheet, full neurological examination pdf, neurological examination checklist
neurological exam documentation template format
5/5 in rt hip flexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors. face is symmetric at rest and with activation with intact sensation throughout. strength is full in sternocleidomastoid and trapezius bilaterally. sensory: sensation is intact to light touch, pinprick, vibration, and proprioception throughout. cranial nerve: pupils are equal, round, and reactive to light. face is symmetric at rest and with activation with intact sensation throughout. strength is full in sternocleidomastoid and trapezius bilaterally.
there is no dysmetria on finger-to-nose and heel-knee-shin. gait is steady with normal steps, base, arm swing, and turning. neuro: mental status: the patient is alert, attentive, and oriented to time, place and person. pupils are 4 mm and briskly reactive to light. cn xi: head turning and shoulder shrug are intact cn xii: tongue is midline with normal movements and no atrophy. tone is increased (rigidity) in both upper and lower extremities and around the neck. there is no dysmetria on finger-to-nose and heel-knee-shin. unauthorized use and/or duplication of this material without express and written permission from this site’s author and/or owner is strictly prohibited.
this is a complete general neurologic exam to be completed on each patient: 1) mental status a. describe how the patient is appearing – best choices include: cn 11. – shrug your shoulders and keep them there. – turn your head to the left and hold it there. – turn your head to the right and hold it there cursory screening/documentation of baseline function for those who are otherwise many examiners incorporate some aspects of the neuro exam into their , neurology templates, neurological examination ppt, neurological examination ppt, pediatric neuro exam template, neurological examination tests, neuro exam template pdf, neuro exam cheat sheet, full neurological examination pdf, neurological examination checklist, neurology templates, neurological examination ppt, pediatric neuro exam template, neurological examination tests
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testing of one system is often predicated on the normal function of other organ systems. a detailed description of the cn assessment is provided below. this is due to the fact that they insert on the eyeball at various angles, and in the case of the superior oblique, thru a pulley. to assess, proceed as follows: pathology: isolated lesions of a cranial nerve or the muscle itself can adversely affect extraocular movement. if there is cn 3 dysfunction, the eyelid on that side will cover more of the iris compared with the other eye. of course, make sure that you do not push too hard as the face is normally quite sensitive. cn 7 is also responsible for carrying taste sensations from the anterior 2/3 of the tongue.
in the setting of a stroke), the uvula will be pulled to the left. an approach to localizing lesions on the basis of motor and sensory findings is described in the sections which follow. sensory testing of the face is discussed in the section on cranial nerves. loss of sensation in this area can be particularly problematic as the feet are a difficult area for the patient to evaluate on their own. patients should be able to correctly identify the motion and direction of the toe. tone: when a muscle group is relaxed, the examiner should be able to easily manipulate the joint through its normal range of motion. if there is weakness, try to identify a pattern, which might provide a clue as to the etiology of the observed decrease in strength. pronator drift is a test for slight weakness of the upper extremities.