neurology history and physical template is a neurology history and physical template sample that gives infomration on neurology history and physical template doc. When designing neurology history and physical template, it is important to consider different neurology history and physical template format such as neurology history and physical template word, neurology history and physical template excel. You may add related information such as medical history sample cases, neuro exam documentation template, neuro exam template note, h p template pdf.
neurology history and physical 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.
sample neurological handp. cc: the patient is a 50-year-old right-handed woman with a history of chronic headaches who complains of acute onset of double uf neurology history and physical guidelines. history. chief complaint — a maximally succinct statement of the patient age, handedness, admission note (initial evaluation). consultation (select one of the three options below:) consult request and reason for consult in sunrise., medical history sample cases, medical history sample cases, neuro exam documentation template, neuro exam template note, h p template pdf
neurology history and physical 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.
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 the links below are to actual handps written by unc students during their inpatient clerkship rotations. the students have granted permission to have these handps these features make the neurologic history and physical or tandem walking maneuvers and standing on 1 leg uncover subtle forms of ataxia., neuro exam template pdf, neurology templates, neurology templates, sample pediatric history and physical write up, assessment and plan example, medical history sample cases, neuro exam documentation template, neuro exam template note, h p template pdf, neuro exam template pdf, neurology templates, sample pediatric history and physical write up, assessment and plan example
neurology history and physical template download
the neurologic examination is one of the most unique exercises in all of clinical medicine. in examining a patient, abnormalities of function lead to localization and, eventually, to the pathophysiology. in the alternating or crossed hemiplegias, cn paralysis is ipsilateral to the lesion, and body paralysis is contralateral. when the lesion is unilateral, the patient may veer to the side of the lesion. the combination of broca and wernicke aphasias is referred to as global aphasia. in other words, the sense of time is first to be impaired in organic dysfunction, and the sense of person is the last to be lost. the following mnemonic is helpful in recalling the names of the cns: oh, oh, oh; to trek and feel a great valley; ah! lesions of cn iii result in paralysis of the ipsilateral upper eyelid and pupil, leaving the patient unable to adduct and look up or down. the nucleus of the nerve is located in the midbrain. isolated paralysis results in esotropia and inability to abduct the eye to the side of the lesion. the lesion is proximal to the departure of the nerve to the stapedius and results in hyperacusis, loss of taste in the anterior two thirds of the tongue, and facial motor weakness. the romberg test is performed to evaluate vestibular control of balance and movement. the nucleus of the nerve lies in the medulla and is anatomically indistinguishable from the cn x and cn xi nuclei (nucleus ambiguous). in testing, functional symmetry of the scm and the trapezius muscles should be evaluated.
muscle tone is the permanent state of partial contraction of a muscle and is assessed by passive movement. pyramidal lesions result in spasticity that may manifest as a clasp-knife phenomenon (ie, resistance to passive movement with sudden giving way, usually toward the completion of joint flexion or extension). the cremasteric reflex is elicited by drawing a line along the medial thigh and watching the movement of the scrotum in the male. flexion of the knee and hip may occur in the paretic leg with urinary and fecal incontinence. in the latter, the patient is asked to walk with 1 foot immediately in front of the other (ie, heel to toe). dysarthria is usually a sign of diffuse involvement of the cerebellum. these are observed in addition to or in the absence of the characteristic blubbery subcutaneous tumors that give the condition its name. in parasympathetic paralysis, the affected pupil is larger and reacts poorly or not at all to light. this is seen with lesions of the median nerve in the axilla and upper arm. this term refers to the difference in color of the 2 irides. lesions in the anterior aspects of the visual pathways decrease the response, and lesions of the vestibular system result in a directional preponderance to the elicited nystagmus. a guide to the performance and interpretation of the neurologic examination. the neurologic examination: incorporating the fundamentals of neuroanatomy and neurophysiology. stephen a berman, md, phd, mba professor of neurology, university of central florida college of medicine stephen a berman, md, phd, mba is a member of the following medical societies: alpha omega alpha, american academy of neurology, phi beta kappadisclosure: nothing to disclose.