Patient name: SUBJECTIVE CC:

Neurology Consult Note Age:

HPI:

PMHx:

Medications:

Allergies: SocHx: Location/living situation: Employment: Married/relationship: Children: FHx:

Smokes: Drinks EtOH: Drug use: MJ/cocaine/heroine/ opiates/BZD/hall

ROS:

Constitutional: Skin/Breast: HEENT: Respiratory: Cardio: GI: GU: MSK: Lymph/Heme: Neuro: Psych: Endocrine:

appetite/weight/sleep, fatigue, fevers Rashes/bumps, dry skin, breast lumps/redness, d/c Visual/hearing s, lumps in neck SOB, cough, hemoptysis, resp inf, night sweats Chest pain, palpitations, murmurs, Abdominal pain, heartburn, N/V/D/constipation, bowels Dysuria, urge, stress, , hematuria, vaginal d/c Muscle pains, leg cramps, back pain, weakness Edema, anemia Tingling/numbness, muscle weakness Depression, anxiety Hot/cold sensitivity, unusual hunger/thirst, hair loss

OBJECTIVE: VS: T= HR= RR= BP= Pain= General: alert and oriented, pleasant, cooperative/uncooperative with interview, NAD/in distress HEENT: NCAT, TM clear/discharge, conjunctiva normal/injected, scleral icterus Fundoscopic exam: Sharp optic disks/fundal papilledema/hemorrhage Neck: Supple, no LAD, no JVD, no carotid bruits, no thyromegaly Cardio: RRR, normal s1/s2, no M/G/R Pulm: CTAB, no crackles/wheezing/rhonchi, chest is non-tender, normal diaphragmatic excursion Abdomen: Soft, NT/ND, + BS. Extremities: No clubbing, cyanosis, edema NEUROLOGICAL EXAM: Mental status: Orientation: +O x 3 (person, time, place) Language: fluent/ mute/ dysphonia/ dysarthria (slurred)/ dysphasia

Cognition (MMSE = ___/30) o Orientation (Year, season, month, day, date) ___/5 o State, county, town, building, floor ___/5 o Apple, table, penny (registration # trials _______) ___/3 o Serial 7s (100, 93, 86, 79, 72, 65) or DLROW ___/5 o Apple, table, penny (recall, #____ w/ semantic cues) ___/3 o Pencil, watch ___/2 o No ifs ands or buts ___/1 o Paper in right hand, fold in half, put on floor ___/3 o Close your eyes ___/1 o Write a sentence ___/1 o Copy pentagons ___/1 Cranial nerves (CNs): CN-2: pupillary reflex (PERRL/ abnormal), visual fields intact, visual acuity = ___/20 CN-3/4/6: EOMI CN-5: Facial sensation intact to light touch/pinprick bilaterally in all 3 divisions. CN-7: Facial movement symmetrical (smile, brow raise, buries eyelashes, puffs cheeks) CN-8: hearing intact to finger rub bilaterally CN-9/10/12: tongue, uvula and pharynx midline, gag reflex CN-11: shoulder & neck have full ROM, SCM & trapezius have symmetrical movements with strength ___/5 Motor: Tone: flaccid / normal / rigid / cogwheeling Strength: Biceps ___/5 Triceps ___/5 SCMs ___/5 Wrist flexors & extensors ___/5 Finger grip ___/5 Finger abductors ___/5 Hip flexors ___/5 Quadriceps ___/5 Plantar flexors & extensors ___/5 Pronator drift: absent/present Abnormal movements: tremor (resting/essential/intention), chorea, hemiballismus, athetosis, dystonia, asterixis, myoclonus, fasciculations, tics, seizures Reflexes: Biceps ___/5 Triceps ___/5 Brachioradialis ___/5 Patellar ___/5 Achilles ___/5 Babinski sign: absent/present Sensory: Sensation intact to: soft touch/ pin-prick/ temperature/ vibration/ proprioception throughout Cerebellar function: Finger-to-nose test: normal / abnormal Heel-to-shin test: normal / abnormal Fast finger movements: normal / abnormal Rapid alternating movements: normal / abnormal Gait: Regular walking/tandem/toes/heels Gait is normal/ hemiparetic/ ataxic/ shuffling/ steppage/ spastic/ antalgic Romberg: absent/present LABS: STUDIES:

ASSESSMENT:

PLANS: