Acute Neurologic Changes – History

Acute Neurologic Changes
Onset [text] prior to evaluation
Onset while:  [text] 

Key Symptoms
[select value="no|YES"] <-- Weakness [text] 
[select value="no|YES"] <-- Change in sensation [text] 
[select value="no|YES"] <-- Facial droop [text] 
[select value="no|YES"] <-- Altered speech [text] 
[select value="no|YES"] <-- Altered swallowing [text] 
[select value="no|YES"] <-- Difficulty standing [text] 
[select value="no|YES"] <-- Vision change [text] 

Associated Symptoms
[select value="no|YES"] <-- Confusion 
[select value="no|YES"] <-- Agitation 
[select value="no|YES"] <-- Difficult to awaken
[select value="no|YES"] <-- Complete Loss of Consciousness (lasted [text] ) 
[select value="no|YES"] <-- Seizure 
[select value="no|YES"] <-- Headache
[select value="no|YES"] <-- Falls [text] 

Pertinent ROS
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- dizziness
[select value="no|YES"] <-- chest pain
[select value="no|YES"] <-- palpitations
[select value="no|YES"] <-- shortness of breath
[select value="no|YES"] <-- cough
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- abdominal pain
[select value="no|YES"] <-- dysuria
[select value="no|YES"] <-- urinary frequency
[select value="no|YES"] <-- rash

Pertinent PMH:
[select value="no|YES"] <-- Atrial Fibrillation
[select value="no|YES"] <-- Cerebrovascular Accident or TIA
[select value="no|YES"] <-- Dementia [text] 
[select value="no|YES"] <-- Coronary Artery Disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Head Trauma
[select value="no|YES"] <-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
[select value="no|YES"] <-- Migraine Headaches
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="" memo="website"][/conditional]
Acute Neurologic Changes
Onset prior to evaluation
Onset while:

Key Symptoms
<-- Weakness
<-- Change in sensation
<-- Facial droop
<-- Altered speech
<-- Altered swallowing
<-- Difficulty standing
<-- Vision change

Associated Symptoms
<-- Confusion
<-- Agitation
<-- Difficult to awaken
<-- Complete Loss of Consciousness (lasted )
<-- Seizure
<-- Headache
<-- Falls

Pertinent ROS
<-- fever
<-- dizziness
<-- chest pain
<-- palpitations
<-- shortness of breath
<-- cough
<-- nausea/vomiting
<-- abdominal pain
<-- dysuria
<-- urinary frequency
<-- rash

Pertinent PMH:
<-- Atrial Fibrillation
<-- Cerebrovascular Accident or TIA
<-- Dementia
<-- Coronary Artery Disease
<-- Diabetes Mellitus
<-- Head Trauma
<-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
<-- Migraine Headaches
display/hide references

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.74, 48 form elements, 152 boilerplate words, 12 text boxes, 1 checkboxes, 33 drop downs, 1 links, 1 conditionals, 46 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: