Neurology Clinic New Patient Note

Reason for consult/ Chief complaint:***

HPI: @M@ @NAME@ is a @AGE@ @SEX@ with a history of ***

Review of systems: All systems are reviewed with the patient with pertinent positives and negatives as per HPI, as well as what is detailed below. All others are negative.

@ROS@

The following portions of the patient's history were reviewed and updated as appropriate:

@PMH@ @PSH@

@MEDACTIVE@

Allergies: @ALLERGIESALL@

@SOCDOC@

@FAMHX@

PHYSICAL EXAM:

VITAL SIGNS: @VITALSIGNS@

GENERAL: Well-nourished, no apparent distress.

EYES: Funduscopic exam shows no evidence of papilledema, exudates, hemorrhage

HEENT: Head without evidence of injury. No tenderness to palpitation of the scalp.

NECK: Supple, no carotid bruit, no lymphadenopathy.

RESPIRATORY: Normal work of breathing with no distress. Symmetric chest expansion.

CARDIOVASCULAR: Heart: Regular rate and rhythm, normal peripheral pulses.

SKIN: No rashes

MUSCULOSKELETAL/EXTREMITIES: No cyanosis or edema

NEUROLOGICAL EXAM:

HIGHER INTEGRATIVE FUNCTIONS:

-Normal attention span and concentration

-Oriented to time, place and person

-Recent and remote memory intact

-Normal language

-Normal fund of knowledge

CRANIAL NERVES:

CN II- Visual fields full to confrontation. CN III, IV, VI- Pupils are round, equally reactive. No ptosis. Full version in all directions, no primary or gaze evoked nystagmus, normal pursuits. CN V- facial sensation to LT intact to V1, V2, V3 b/l. CN VII- symmetric smile without droop and no weakness of muscles of facial expression. CN VIII- hearing intact b/l. CN IX, X- symmetric palate elevation, uvula is midline. CN XI- normal shoulder shrug and head turn. CN XII- tongue protrusion is midline. No weakness of tongue, atrophy or fasiculations

MOTOR: Tone: normal in upper and lower extremities. UE/LE power: 5/5 throughout

SENSORY: Sensation normal bilaterally to light touch, pinprick, temperature, vibration

REFLEXES: DTRs 2/4 in upper and lower extremities bilaterally. Flexor plantar reflex bilaterally

COORDINATION: FNF, HKS, RAM normal bilaterally

GAIT & STATION: Normal casual and tandem gait

DATA:

Labs (I have personally reviewed the results of these labs and pertinent labs are as follows):

@LASTLAB(RBC,HGB,HCT,MCV,MCH,MCHC,RDW,PLT,MPV)@

@RESUFAST(BUN,CREATININE,NA,K,CL,CO2)@

@RESUFAST(NA,K,CL,CO2,ANIONGAP,BUN,CREATININE,EGFR,GLU,CALCIUM,BILITOT,AST,ALT,PROT,ALBU,AGRATIO,ALKPOS)@

@LASTLAB(CHOL,TRIG,HDL,VLDL,CHOLHDL,LDL)@

@RESUFAST(INR:3,PROTIME:3)@

@LASTA1C@

@RESUFAST(VITAMINB12)@

@RESUFAST(FOLATE)@

@RESUFAST(TSH,T3TOTAL,T4TOTAL,THYROIDAB)@

Images ( I have personally reviewed these images and the results are as follows).:

***

IMPRESSION:

@M@ @NAME@ is a @AGE@ @SEX@ with a history of ***

ASSESSMENT AND PLAN:

@ASSESSPLAN@

***