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    Compre Guide For HX and PE - Neuro

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    Sebastian Smythe

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    © All Rights Reserved
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    Compre Guide For HX and PE - Neuro

    Uploaded by

    Sebastian Smythe
    10 views6 pages

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    Compre Guide for Hx and PE - Neuro

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    10 views6 pages

    Compre Guide For HX and PE - Neuro

    Uploaded by

    Sebastian Smythe

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 6

    HISTORY

    General Data
    Name (Guardian)
    Age/ Sex
    Handedness
    Marital Status
    Educational
    Attainment
    Occupation
    Religion
    Residence
    Province
    Chief Complaint/ History of Present Illness
    Onset / Course
    Provocation
    Palliation
    Quality
    Region/ Radiation
    Severity
    Time
    Associated
    Symptoms

    REVIEW OF SYSTEMS
    System (+/-)
    (-) change in appetite, (-) fever or chills, (-) fatigue, (-) weight gain, (-) weight loss, (-) muscle
    Constitutional
    ache , (-) change in sleeping pattern/time
    Head (-) headache, (-) head injury, (-) dizziness
    Ears (-) hearing loss, (-) tinnitus, (-) ear ache, (-) ear discharge
    (-) use of glasses/contacts (OS: ; OD: ), (-) astigmatism, (-) vision loss or changes, (-) eye
    Eyes
    discharge, (-) eye pain, (-) eye redness, (-) blurry vision, (-) double vision, (-) flashing lights
    Nose (-) nasal stuffiness, (-) nasal discharge, (-) nasal pruritus, (-) epistaxis, (-) sinus pain
    (-) gum bleeding, (-) sore tongue, (-) sore mouth, (-) dry mouth, (-) sore throat, (-) hoarseness,
    Throat (-) oral thrush, (-) dental caries, (-) lumps, (-) neck pain, (-) neck stiffness, (-) dysphagia, (-)
    dysarthria
    (-) cough, (-) colds, (-) sputum (-)​hemoptysis, (-) wheezing, (-) painful breathing, (-) shortness
    Respiratory
    of breath
    (-) chest pain, (-) chest tightness, (-) palpitations, (-) orthopnea (-) Paroxysmal Nocturnal
    Cardiovascular
    Dyspnea
    (-) abdominal pain, (-) nausea, (-) changes in bowel habits, (-) flatulence, (-) heartburn,
    Gastrointestinal (-) constipation, (-) melena, (-) hematochezia, hematemesis, (-) difficulty swallowing, (-)
    tenesmus
    (-) polyuria, (-) dysuria, (-) nocturia, (-) hematuria, (-) myoglobinuria, (-) incontinence, (-)
    difficulty or pain in urinating, (-) change in urinary strength
    Frequency of urination: frequent; 8x a day
    Genitourinary
    Urine Color: light yellow
    (-) vaginal discharge, (-) foul odor, (-) menorrhagia, (-) dysmenorrhea, (-) amenorrhea, (-)
    pruritus, (-) dyspareunia
    Extremities (-) edema, (-) arthralgia, (-) stiffness, (-) back pain, (-) trauma, (-) pain

    (-) jaundice, (-) pallor, (-) cyanosis, (-) petechiae, (-) ecchymoses, (-) rashes, (-) masses, (-)
    Skin
    pruritus, (-) dryness, (-) hair or nail changes

    Neurologic (-) syncope, (-) seizures, (-) weakness (-) numbness, (-) paresthesias, (-) tremor
    Endocrine (-) polydipsia, (-) polyphagia, (-) polyuria, (-) heat/cold intolerance, (-) hair loss
    (-) nervousness, (-) stress, (-) depression, (-) memory loss, (-) hallucinations, (-) delusions, (-)
    Psychiatric
    illusions

    OTHER HISTORY INFORMATION


    Asthma Surgery
    Allergies Polycystic Ovarian Syndrome
    Allergic Rhinitis Thyroid enlargement
    Atopic Dermatitis Liver Disease
    Chickenpox Kidney Disease
    Past Medical Mumps Heart Disease
    History Measles Stroke
    Mental Illness Polio
    Pneumonia Hospitalization
    Tuberculosis Injuries
    Diabetes Trauma
    Cancer Others:
    Hypertension
    Diabetes
    Family Medical
    Heart Disease
    History
    Autoimmune Disease
    Others: ______________________
    Dietary habits
    ●
    Smoking history
    ●
    Alcohol intake
    Personal and ●
    Social History Illicit drug use
    ●
    Travel history
    ●
    Sexual history
    ●
    Obstetric and ● LMP
    Gynecologic ● PMP
    ● Menarche age
    ● Menstrual duration
    ● Light/ moderate/ heavy
    ● # of pads per day
    Dysmenorrhea (relieved w/ _______________)
    Sexually active
    Contraceptive use: _______________
    ● Obstetric score

    PHYSICAL EXAM
    Systemic PE (sample)
    ● General Survey: awake, not in cardiorespiratory distress
    ● Vital Signs: BP: 120/70 HR: 84 (regular) RR: 20 Temperature: 36.7°C O2 sat:
    ● HEENT: Pink conjunctiva, anicteric sclerae, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion, (-)
    neck vein engorgement, no carotid bruits, no anterior neck mass
    ● Chest/Lungs: (-) chest deformities, midline trachea, (-) palpable masses, symmetrical chest expansion (no chest
    lag), clear breath sounds, (-) adventitious sounds, (-) retractions, (-) use of accessory respiratory muscles
    ● CVS: Adynamic precordium, distinct heart sounds, normal heart rate and rhythm, no murmurs, (-) heaves, thrills
    ● Abdomen: Soft abdomen (-) masses/tenderness on palpation, normoactive bowel sounds
    ● Skin / Extremities: good skin turgor, pink nailbeds, full and equal pulses, no cyanosis, no clubbing, no jaundice
    ● DRE: Good sphincter tone, empty rectal vault, no stool/blood per examining finger

    Mental Status Assessment


    Link to MMSE Questionnaire (Filipino) + Instructions to Administrators
    Mental Status Assessment – Listed below are normal findings, change as needed
    Normal: Awake, follows commands
    Sensorium
    Others: drowsy (can be aroused upon light tapping), stuporous (reacts with pain), comatose
    Well groomed, dressed appropriately for age, converses spontaneously
    Euthymic mood, appropriate affect, no hallucinations, illusions or delusions
    Mental Status Exam
    Good fund of information, concentration, calculation, insight and judgment
    Calculations intact

    Cranial Nerves – Listed below are normal findings, change as needed


    CN I (Olfactory) Absence of nasal obstruction, identification of substance (intact olfactory sense)
    Visual acuity: 20/20 OU
    No visual field cuts by confrontation
    CN II (Optic)
    Pupils 3mm EBRTL, intact direct and consensual light reflex
    Fundoscopy findings: (+) red orange reflex, clear media, distinct disc borders, no papilledema
    CN III, IV, VI
    Primary gaze midline, symmetrical eyes, and no observable ptosis
    (Oculomotor, Trochlear,
    Follows 6 cardinal gazes with good accommodation, no extraocular muscle paresis and palsies
    Abducens)
    Intact sensation to pinprick, light touch on V1-V3, good masseter and lateral pterygoids tone,
    CN V (Trigeminal)
    brisk corneal reflex
    CN VII (Facial) Symmetrical facial expression (no facial palsy), no ageusia (can identify substance correctly)
    CN VIII No gross hearing defects. Air conduction > bone conduction in both ears. No lateralization in
    (Vestibulocochlear) both ears
    CN IX, X
    (Glossopharyngeal and Good gutturals, equal palatal elevation, no dysphonia, intact gag reflex
    Vagus)
    CN XI (Spinal Accessory) Intact sternocleidomastoid and trapezius strength
    CN XII (Hypoglossal) Tongue midline on protrusion, no fasciculations

    Motor Exam – Listed below are normal findings, change as needed


    Upper and lower
    No atrophy, hypertrophy, asymmetry, joint contractures, fasciculations, involuntary movements
    extremities (Inspection,
    No spasticity, rigidity, flaccidity
    tone, range of motion,
    No subtle weakness
    strength)
    Guide:
    0/5 No movement

    1/5 Flicker of contraction

    2/5 Movement, eliminated gravity


    Manual Motor Testing
    3/5 Full ROM against gravity, not against resistance

    4/5 Moves against resistance, but weak

    5/5 Normal strength

    Muscle group R L Muscle group (LE) R L


    (UE)

    Shoulder /5 Hip flexion


    abduction

    Shoulder Hip extension


    adduction

    Elbow flexion Hip abduction

    Elbow extension Hip adduction

    Wrist flexion Knee flexion

    Wrist extension Knee extension

    Finger flexion Foot dorsiflexion

    Finger extension Foot plantarflexion

    Finger abduction Foot inversion

    Finger adduction Foot eversion

    Toe extension
    Reflexes
    Muscle
    Check for biceps, brachioradialis, triceps, knee, ankle reflexes
    stretch
    Abnormal (-) Clonus, (-) Tromner, (-) Hoffman, (-) Babinski (flexor response)
    reflexes If needed, check: Chaddock, Schaffer, Gordon, Oppenheim
    0/5 Absent (areflexia)

    +/- Present only with reinforcement (Jendrassik


    maneuver)

    1+ Hypoactive

    2+ Normal

    3+ Hyperactive

    4+ Hyperactive with unsustained clonus

    5+ Sustained clonus

    Cerebellar – Listed below are normal findings, change as needed


    Normal rate and rhythm, fluent, no dysphonia, no dysarthria (slowness, slurring of words,
    Speech
    scanning speech)
    Eye movements No nystagmus
    No dysmetria, no intentional tremors
    Finger-to-nose test
    Able to smoothly trace a straight line from the nose to the examiner’s fingertip
    Wrist slapping test No overshooting, no arm oscillation, no pronator drift
    No overshooting
    Arm pulling test
    Arm flies upward by a small distance, rebounds, and quickly resumes resting position
    No dysdiadochokinesia
    Thigh slapping test
    Consistent hand movements and comparable with that of examiner
    No dysmetria
    Heel to shin
    Heel does not fall off the opposite knee or shin
    Posture, stance, and
    No truncal ataxia, normal standing and sitting posture, normal tandem walk and gairt
    gait
    Sensory – Listed below are normal findings, change as needed
    Intact pain sensation on both UE and LE
    Pain, temperature Able to sense pain and temperature stimulus symmetrically and proximal vs distal, correctly
    responds whether a stimulus is being applied or not
    Intact light touch sensation on both UE and LE
    Light touch Able to sense light touch symmetrically and proximal vs distal, correctly responds whether a
    stimulus is being applied or not
    Intact vibration sensation on both UE and LE
    Vibration Able to sense vibration symmetrically and proximal vs distal, able to tell when the vibration
    stops
    Intact position sense on both UE and LE
    Position sense
    Able to tell all the position the 4th digit is in
    Normal Romberg test
    Romberg test
    Steady and did not fall over

    Meningeals – Listed below are normal findings, change as needed


    Nuchal rigidity Patient/examiner can flex the neck
    Brudzinki’s sign No adduction/flexion of the hip/knee while testing for nuchal rigidity
    Patient does not wince with pain upon straightening the knee
    Kernig’s sign
    No reflex hamstring spasm preventing further straightening of the knee

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