neurology consult note template is a neurology consult note template sample that gives infomration on neurology consult note template doc. When designing neurology consult note template, it is important to consider different neurology consult note template format such as neurology consult note template word, neurology consult note template excel. You may add related information such as neuro exam template pdf, neurology templates, neurology progress note, medical history sample cases.
neurology consult note 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.
mrs. smith also notes that for the past two to three weeks, she has been she denies previous episodes of transient or permanent visual or neurologic changes. 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 neurology consult note template – free download as word doc (.doc / .docx), pdf file (.pdf), text file (.txt) or read online for free., neuro exam template pdf, neuro exam template pdf, neurology templates, neurology progress note, medical history sample cases
neurology consult note 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.
neurology consult note. consult date: @td@. referring physician: @admprovtitle@. reason for consult. i have been asked to see the patient in admission note (initial evaluation). consultation (select one of the three options below:) consult request and reason for consult in sunrise. two templates have been provided: one for older children, and it is very important that referring physicians and other care physicians get a copy of the clinic letter. thank you for referring (patient’s full name) to the pediatric neurology clinic , neuro exam cheat sheet, pediatric neuro exam template, pediatric neuro exam template, neurological examination checklist, full neurological examination pdf, neuro exam template pdf, neurology templates, neurology progress note, medical history sample cases, neuro exam cheat sheet, pediatric neuro exam template, neurological examination checklist, full neurological examination pdf
neurology consult note template download
the top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation. this was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page. since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication.