neurology hpi template is a neurology hpi template sample that gives infomration on neurology hpi template doc. When designing neurology hpi template, it is important to consider different neurology hpi template format such as neurology hpi template word, neurology hpi template excel. You may add related information such as neuro exam template note, neuro exam documentation template, neuro exam template pdf, neurology templates.
neurology hpi 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 family risk factors for neurologic diseases (e.g. migraine, epilepsy, the hpi. list systems reviewed. for a complete work-up, the requirement is for 10 to 14. 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 note, neuro exam template note, neuro exam documentation template, neuro exam template pdf, neurology templates
neurology hpi 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.
admission note (initial evaluation). consultation (select one of the three options below:) consult request and reason for consult in sunrise. patient name: subjective cc: neurology consult note age: hpi: pmhx: medications: allergies: sochx: location/living situation: the written history and physical (handp) serves several purposes: for misinformation to be perpetuated when past write-ups or notes are used as the template for new handps. neurology service evaluated patient and ct head obtained., neurological examination checklist, medical history sample cases, medical history sample cases, neurological exam questions, neuro exam mnemonic, neuro exam template note, neuro exam documentation template, neuro exam template pdf, neurology templates, neurological examination checklist, medical history sample cases, neurological exam questions, neuro exam mnemonic
neurology hpi template download
while this has traditionally been referred to as the chief complaint, chief concern may be a better description as it is less pejorative and confrontational sounding. this format is easy to read and makes bytes of chronological information readily apparent to the reader. a brief review of systems related to the current complaint is generally noted at the end of the hpi. when dealing with this type of situation, first spend extra time and effort assuring yourself that the symptoms are truly unconnected and worthy of addressing in the hpi. also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have. so, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data.
pertinent positives and negatives related to the chief concern) are generally noted at the end of the hpi. the swelling was accompanied by a weight gain of 10lb in 2 days (175 to 185lb) as well as a decrease in his exercise tolerance. he now becomes dyspneic when rising to get out of bed and has to rest due to sob when walking on flat ground. onset was abrupt and he first noted this when he “couldn’t see the clock” while at a restaurant. over the past few days he has noted increased dyspnea, wheezing, and sputum production. story of the sudden onset of neurologic deficits while awake, in the setting of newly identified atrial fibrillation, is most consistent with a cardio-embolic event. of note, as last known normal was > 24 hours ago, he is outside the window to receive tpa or device driven therapy.