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Neuro Chart Outline

The document appears to be a medical assessment template that includes sections for patient demographics, history of present illness (HPI), past medical history (PMH), medications, social history, and a detailed neurological examination. It outlines various systems to assess, including constitutional, eyes, ENT, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, and psychiatric. The document is structured to facilitate a comprehensive evaluation of a patient's health status and plan for further care.

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stephanie.provo98
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27 views2 pages

Neuro Chart Outline

The document appears to be a medical assessment template that includes sections for patient demographics, history of present illness (HPI), past medical history (PMH), medications, social history, and a detailed neurological examination. It outlines various systems to assess, including constitutional, eyes, ENT, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, and psychiatric. The document is structured to facilitate a comprehensive evaluation of a patient's health status and plan for further care.

Uploaded by

stephanie.provo98
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Age, Name, Ethnicity: Smoking:

CC: Alcohol:

HPI: O: Drugs:

L: Work:

D: ROS:

C: Constitutional: Weight loss/gain, fever, chills

A: Eyes: eye pain, vision changes

R: ENT: sore throat, congestion, ear pain

PE: Chest: palpitations, chest pain

T: Respiratory: SOB. Cough

S: GI: n/v/d

Prior diagnostic and treatment results: Genitourinary: incontinence

PMH: MSK: Joint pain

Skin: rashes, cuts, bruises

Allergies: Neuro: memory issues, dizziness, confusion, numbness,


tingling, weakness, headaches
Surgical Hx:
Psych: anxiety, depression
FMH:
Exam:
Parents:
Mental Status:
Grandparents:
Oriented to person, place, and time.
Siblings:
Recall at 5 minutes:
Children:
Attention:
Medications: DOSES!
Concentration:

Speech:

Level of consciousness:
Social History:
Knowledge:
Normal comprehension. Biceps

Cranial Nerves: Brachioradialis

CNII – VA/visual fields, opthalmascope Patellar

CNIII, IV, VI – H test, light reflex, pupillary reflex Achilles

CN V – sensory/motor of face Sensation:

CNVII – smile, raise eyebrows, puff out cheeks Light touch normal. Pinprick normal

CN VIII – finger rub Vibration sensation.

CN IX, X – palate elevation R L

CN XI – shoulder shrug, head turn UE

CN XII – tongue motility LE

Strength: 5/5 throughout if normal Pinprick normal.

Shoulder abd Romberg

Shoulder add Stereognosis

Elbow flexion Graphesthesia

Elbow extension Finger to nose, rapid alternating, heel to shin

Wrist flexion Causal gait, tandem, toe and heel walk

Wrist extension Assessment:

Finger abduction Age with diagnosis and assessment of current status or


diagnosis and why.
Hip flexion

Knee flexion
Plan: what is going to be ordered? Continue care? Follow up when?
Knee extension

Plantarflexion

Dorsiflexion

DTR:

Triceps

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