neurological report sample for stroke patient

Why was I unable to get a Complete neurologic exam?

Was unable to get a complete neurologic exam due to language difficulties. We would like a MRI and MRA of the brain for further evaluation. Will also like to check the results of carotid duplex and 2D echocardiogram. Agree with antiplatelet therapy.

Where can I find more information on acute ischemic stroke treatment?

For more information on Acute Ischemic Stroke treatment, go to StrokeAssociation.org/AISToolkit Title PowerPoint Presentation Author Lindsey Minton Created Date 11/18/2016 2:25:23 PM

How do you write a case report for a hospital?

Modern case reports typically include a title, abstract, introduction, case presentation, discussion, conclusion, and references. Even as the format evolves, the most important element remains the patient and his or her story, and constructing the case report begins with the patient.

How do you document neurological findings?

Documentation of a basic, normal neuro exam should look something along the lines of the following: The patient is alert and oriented to person, place, and time with normal speech. No motor deficits are noted, with muscle strength 5/5 bilaterally. Sensation is intact bilaterally.

What are the 5 components of a neurological examination?

The neurologic examination is typically divided into eight components: mental status; skull, spine and meninges; cranial nerves; motor examination; sensory examination; coordination; reflexes; and gait and station. The mental status is an extremely important part of the neurologic examination that is often overlooked.

What are the 7 areas of documentation of the neurological exam?

The neurological exam can be organized into 7 categories: (1) mental status, (2) cranial nerves, (3) motor system, (4) reflexes, (5) sensory system, (6) coordination, and (7) station and gait. You should approach the exam systematically and establish a routine so as not to leave anything out.

What are the components of a neurologic exam for ischemic stroke?

There are many aspects of this exam, including an assessment of motor and sensory skills, balance and coordination, mental status (the patient's level of awareness and interaction with the environment), reflexes, and functioning of the nerves.

What is a full neurological exam?

A complete neurologic examination should contain an assessment of sensorium, cognition, cranial nerves, motor, sensory, cerebellar, gait, reflexes, meningeal irritation, and long tract signs. Specific scales are useful to improve interobserver variability.

How do nurses measure neurological status?

A thorough neurologic assessment will include assessing mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs. However, unless you work in a neuro unit, you won't typically need to perform a sensory and cerebellar assessment.

What is the most reliable indicator of a patient's neurologic function?

A patient's mental status is the most reliable indicator of brain function, so when there is altered mental status, obtaining a history and assessing for cerebellar function, weakness and paresthesia becomes far more difficult.

What neurological assessments do you use to identify a stroke?

There are multiple scales that are commonly used worldwide in the assessment of stroke victims, including the five listed below:National Institutes of Health Stroke Scale (NIHSS)Cincinnati Prehospital Stroke Scale (CPSS)Face Arm Speech Test (FAST)Los Angeles Prehospital Stroke Screen (LAPSS), and.More items...

What are the three components of a neurological exam?

The cranial nerve exam tests the sensory and motor functions of each of the nerves, as applicable. Two major sections, the sensory exam and the motor exam, test the sensory and motor functions associated with spinal nerves. Finally, the coordination exam tests the ability to perform complex and coordinated movements.

How do you evaluate a stroke patient?

Some of the tests you may have include:A physical exam. Your doctor will do a number of tests you're familiar with, such as listening to the heart and checking the blood pressure. ... Blood tests. ... Computerized tomography (CT) scan. ... Magnetic resonance imaging (MRI). ... Carotid ultrasound. ... Cerebral angiogram. ... Echocardiogram.

What is a neurological exam?

The neurological exam consists of a number of components that assess for neurological abnormalities. The level of detail of the neurological exam performed in the clinical setting varies with each patient depending on history and symptoms. Patients presenting with neurological deficits, or symptoms of neurological conditions, for example, ...

What is neuro exam?

A neuro exam is one of the more complex body systems to master when it comes to assessment and documentation. Testing the cranial nerves, for example, takes practice. Omitting a small part of the process can mean missing a potentially serious diagnosis.

Do you need a neurological assessment?

Patients presenting with neurological deficits, or symptoms of neurological conditions, for example, may require a complete neurological assessment. Patients presenting for non-neurological complaints may only require a simple assessment of mental status.