Neuro Note

<: SUBJECTIVE :>

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(CC): Consulted by { }

(HPI):

 { } 

  - Location: { }

  - Quality: { }

  - Frequency: { }

  - Duration: { }

  - Severity: Average { }/10, worst { }/10

  - Handedness: {Right}{Left}

{HEADACHE}

  - Additional Symptoms: {YES}{no} photophobia, {YES}{no} phonophobia, {YES}{no} nausea, {YES}{no} vomiting, {YES}{no} jaw claudication, {YES}{no} neck/shoulder pain, {YES}{no} scalp tenderness, {YES}{no} ptosis, {YES}{no} lacrimation, {YES}{no} sclera injection, {YES}{no} miosis, {YES}{no} rhinorrhea.

  - Aura: {YES}{no} visual symptoms, {YES}{no} numbness, {YES}{no} weakness, {YES}{no} paresthesias.

  - Triggers/exacerbants: {YES}{no} sleep deprivation, {YES}{no} stress, {YES}{no} foods, {YES}{no} dehydration, {YES}{no} exertion, {YES}{no} menses.

  - Sleep: { }

  - Caffeine: { }

  Abortive Agents

  - Current: { }

  - Prior: 

  Prophylactic Agents

  - Current: { }

  - Prior: 

  OTC medications:

  - Current: { }

  - Prior: 

  - Family History of Headache: { } 

  - Prior Imaging: { } 

  - Prior Head Injuries/Head Trauma: {none}

  - Post Concussive Symptoms:  {YES}{no} sleep problems,  {YES}{no} memory problems,  {YES}{no} mood swings,  {YES}{no} lightheadedness,  {YES}{no} vertigo,  {YES}{no} gait imbalance,  {YES}{no} stuttering.

{SEIZURE HISTORY}

  - Prior history of seizures/epilepsy: {no}

  - Family history of seizures/epilepsy:  {no}

  - Prior history of meningitis/encephalitis: {no}

  - Birth history: {uncomplicated}

  - Bladder/bowel incontinence: {no}

  - Tongue/buccal trauma: {no}

  - Alcohol/illicit drugs: {denies}

  - State of driver’s license: {state}

  - Plans for pregnancy: {unsure}

(REVIEW OF SYSTEMS):

Gen: {no} fevers, {no} chills, {no} flu symptoms, {no} weight loss/gain, {no} night sweats.

Psych: {no} depression, {no} anxiety, {no} suicidal ideation, {no} homicidal ideation.

HEENT: {no} vision changes/loss, {no} sore throat, {no} hearing loss/changes, {no} speech/swallow difficulties.

CV: {no} chest pain, {no} palpitations.

RESP: {no} shortness of breath, {no} cough.

GI: {no} pain, {no} nausea, {no} vomiting, {no} diarrhea, {no} constipation, {no} fecal/urinary incontinence. 

GU: {no} sexual difficulties, {no} urinary difficulties.

MS: {no} joint/muscle pains, {no} swelling, {no} redness.

SKIN: {no} rashes, {no} easy bruising.

NEURO: {no} numbness, {no} paresthesias, {no} weakness, {no} loss of consciousness, {no} vertigo, {no} ataxia,  {no} headache.

<: PAST HISTORY :>

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(MEDICAL HISTORY):

 - { }

(SURGICAL HISTORY):

 - { }

{(OB/GYN HISTORY):

 - { }

}

(SOCIAL HISTORY):

 - { }

(FAMILY HISTORY):

 - { }

(ALLERGIES):

 - {}NKDA

(CURRENT MEDICATIONS):

 - { }

<: OBJECTIVE :>

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(PHYSICAL EXAM):

VS reviewed above

GENERAL: Well-developed well-nourished, {fe}male in no apparent distress.

HEENT: NCAT, oral mucosa w/o ulcers or inflammation. No trigger point.

CV: RRR nl S1S2

RESP: CTAB

DERM: no skin changes or rashes. 

MS: no joint swelling, erythema or tenderness. 

MENTAL STATUS: Pt was alert and oriented x3 with intact language, attention, concentration, recent/remote memory and fund of knowledge per patient interview.

CRANIAL NERVES:

CN II pupils equal, round reactive to light, visual fields full to confrontation, fundi without pallor, edema or vascular changes.  CN III/IV/VI extraocular movements intact, negative palsies.   Normal pursuits and saccades CN V face symmetric to LT. Corneal reflex not tested. CN VII facial muscles symmetric, negative droop or palsy.  CNVIII grossly intact to finger rub. CN IX/X palate raise symmetric. Gag reflex not tested. CN XI sternocleidomastoid and trapezius 5/5 strength bilaterally. CNXII tongue midline without fasciculations, atrophy or deviations.

MOTOR: 5/5 strength in all extremities. Normal tone and bulk. Negative pronator drift.

SENSATION: intact to light touch, proprioception, vibration, pinprick in all extremities.  Romberg absent.

CEREBELLAR: finger-to-nose,  heel-to-shin, fine finger movements and rapid alternating hand movements intact bilaterally.

DTRs: 2/4 throughout with down going toes bilaterally.

GAIT: intact toe, heel, tandem and casual gait. 

<: ASSESSMENT & PLAN :>

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{DX} - 

  {Plan}

{DX} - 

  {Plan}

A portion of this encounter was spent on educating the patient regarding the diagnosis, expected course and outcome, diagnostic studies, therapeutic interventions and follow-up. A copy of this consult was made available to the consulting provider via the electronic medical record. Medication reconciliation was done, per patient interview, and there are no additional medications to those listed above. A written plan of care was provided to the patient.