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neurology 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.
she denies head trauma, recent illness, fever, tinnitus or other neurologic symptoms. she is not aware of a change in her appearance, but her husband notes in practice, the neurological exam is tailored to the patient’s symptoms and cooperation (but note that reflexes can be reinforced or decreased voluntarily to some extent, as simple and complex forms, drawing a clock). 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, neurology templates, neuro exam cheat sheet, neurological examination checklist
neurology 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.
templates for stroke alert and morning rounds here you can type your note and send it to your email. templates for normal neurological examination. neurology consult note template – free download as word doc (.doc / .docx), pdf file (.pdf), text file (.txt) or read online for free. this is a complete general neurologic exam to be completed on each patient: note, it is not helpful to use words like “obtunded” or “somnolent” as these do., full neurological examination pdf, pediatric neuro exam template, pediatric neuro exam template, medical history sample cases, neurological assessment pdf, neuro exam template pdf, neurology templates, neuro exam cheat sheet, neurological examination checklist, full neurological examination pdf, pediatric neuro exam template, medical history sample cases, neurological assessment pdf
neurology note template download
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