SOAP for Neurology

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Neurological SOAP Note

Tell a Friend. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed or removed to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.

Home Sitemap. Adult Hydrocephalus The patient is a year-old woman who presents for neurological consultation for possible adult hydrocephalus. Well-woman examination Vaginal examination Breast examination Cervical motion tenderness. Medical diagnosis Differential diagnosis. Craniotomy Decompressive craniectomy Cranioplasty. Thalamotomy Thalamic stimulator Pallidotomy.

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Ventriculostomy Suboccipital puncture Intracranial pressure monitoring. Psychosurgery Lobotomy Bilateral cingulotomy Multiple subpial transection Hemispherectomy Anterior temporal lobectomy. Brain biopsy. Meningeal biopsy. Spinal cord and roots Cordotomy Rhizotomy Vertebrae and intervertebral discs : see Template:Bone, cartilage, and joint procedures. Electroencephalography Lumbar puncture Polysomnography.

Nerve block Vagotomy. Ganglionectomy Sympathectomy Endoscopic thoracic sympathectomy. Axotomy Neurectomy Nerve biopsy. Nerve conduction study Electromyography. Magnetic resonance neurography. Categories : Neurology procedures Physical examination. Hidden categories: All articles with unsourced statements Articles with unsourced statements from April Namespaces Article Talk.

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The human nervous system. Mental status examination. The assessment of consciousness , often using the Glasgow Coma Scale GCS Mental status examination , often including the abbreviated mental test score AMTS or mini mental state examination MMSE Global assessment of higher functions Intracranial pressure is roughly estimated by fundoscopy ; this also enables assessment for microvascular disease.

Cranial nerve examination. These are tested by their individual purposes e.

Neurology - Transcribed Medical Transcription Sample Reports and Examples

Muscle strength, often graded on the MRC scale 0 to 5 [4] i. Muscle tone and signs of rigidity. Examination of posture Decerebrate Decorticate Hemiparetic Resting tremors Abnormal movements Seizure Fasciculations Tone Spasticity Pronator drift Rigidity Cogwheeling abnormal tone suggestive of Parkinson's disease Gegenhalten — is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force.

More common in dementia. Deep tendon reflexes. Reflexes : masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar i. Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract , while decreased reflexes suggest abnormality in the anterior horn , LMN , nerve or motor end plate.

A reflex hammer is used for this testing. Sensory Light touch Pain Temperature Vibration Position sense Graphesthesia Stereognosis , and Two-point discrimination for discriminative sense Extinction Romberg test — 2 out of the following 3 must be intact to maintain balance: i.

Cerebellar testing Dysmetria Finger-to-nose test Ankle-over-tibia test Dysdiadochokinesis Rapid pronation-supination Ataxia Assessment of gait Nystagmus Intention tremor Staccato speech. Digestive Liver span Rectal Murphy's sign Bowel sounds. Brain thalamus and globus pallidus : Thalamotomy Thalamic stimulator Pallidotomy.

Cranial and peripheral nerves Nerve block Vagotomy.