neurology progress note template is a neurology progress note template sample that gives infomration on neurology progress note template doc. When designing neurology progress note template, it is important to consider different neurology progress note template format such as neurology progress note template word, neurology progress note template excel. You may add related information such as neuro exam template note, neuro exam template pdf, neurology templates, neuro exam cheat sheet.
neurology progress 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.
sample neurological handp. cc: mrs. smith also notes that for the past two to three weeks, she has been having intermittent pounding bifrontal headaches that 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 progress note. @hdays@. subjective: @name@ is a @age@ @sex@ with ***. pmhx, sh, fh, and ros are otherwise unchanged since my last , neuro exam template note, neuro exam template note, neuro exam template pdf, neurology templates, neuro exam cheat sheet
neurology progress 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 template – free download as word doc (.doc / .docx), pdf file (.pdf), text file (.txt) or read online for free. neuro soap note template. date, time. ms3pn. s: any complaints the pt has, how they are doing, what happened yesterday. o: vitals (tmax, pulse (min-max), subjective: the patient is an (xx)-year-old right-handed female who has been followed by dr. john doe for paresthesias of uncertain etiology. her most , neurological examination checklist, stroke soap note, stroke soap note, neuro assessment format, full neurological examination pdf, neuro exam template note, neuro exam template pdf, neurology templates, neuro exam cheat sheet, neurological examination checklist, stroke soap note, neuro assessment format, full neurological examination pdf
neurology progress note template download
her most notable complaint this visit is burning paresthesias in the left lateral thigh, which has been present for quite some time. she does have a known history of an l5-s1 disk herniation and stenosis, which was mild on her last imaging study. objective: vital signs: heart rate 76, blood pressure 130/72, respiratory rate 14. general: she is a pleasant female who appears younger than her stated age. she is a good historian and is able to give accurate details of her recent and remote history. cranial nerves: pupils were equal, round, and reactive to light. face was symmetric with full strength and sensation. motor: normal tone and bulk, 5/5 strength in all extremities. she is able to toe walk, heel walk and do tandem gait.
assessment and plan: the patient is an (xx)-year-old right-handed female with multiple complaints but a quite benign neurologic exam and neurologic workup. in general, he is doing about the same. he tries to stay active, going to the gym frequently, working on the treadmill and bicycling. objective: the patient is a very pleasant hispanic male in no acute distress. tone in the neck is scored as a 1 on the updrs. he has really very little tremor today, and there is just a slight shiver of tremor in the left upper extremity at rest. his tone is scored as a 1.5 in the left upper extremity, 0.5 in the left lower extremity, and normal on the right. assessment and plan: this is a (xx)-year-old man with idiopathic young-onset parkinson disease. he should continue with his daily exercise, and we will schedule him for a followup in six months.