Neuro SOAP note template

Date, time

MS3PN​

S: any complaints the pt has, how they are doing, what happened yesterday​

O: Vitals (Tmax, Pulse (min-max), Respiration (min-max), BP (min-max), SaO2)

Ins and Outs (over 24h). *note last BM when going to Dodd

Exam:

General: how does patient appear?

CV: RRR (regular rate and rhythm)?, normal S1 and S2?, no m/r/g (murmurs/rubs/gallops)?, peripheral pulses 2+ bilaterally?, peripheral edema?

Lungs: CTAB (clear to auscultation bilaterally)?, no wheezes/rales/rhonchi?, no accessory muscle use?

Abd: soft?, NT/ND (nontender/nondistended)?, bowel sounds normal?, no palpable masses or organomegaly?

Mental Status: awake/somnolent/drowsy/arousable (to pain/name, etc?)/ comatose

CN : EOMI (extraoccular mvts intact), PERRLA (pupils equally round and reactive to light and accommodation), face symmetric/droop, palate elevation symmetric/asymmetric, facial sensation intact ?/ tongue midline?

* what to test with CN’s

​II: visual acuity, fields, pupils

​III, IV, VII: extraoccular movements, corneal reflex (if you are mean)

​V, VI: facial sensation, movement

​IX, X, XII: palate tongue, gag reflex, shoulder shrug/SCM

Motor: tone (nl/spastic/flaccid)

​Bulk: atrophy?

​Strength:

               SA/EF/EE/WE/WF/DI/HF/KE/DF/PF

​R ____________________________________

​L

*(shoulder abd, elbow flex, elbow ext, wrist flex, wrist ext, dorsal interossi, hip flex, knee flex, dorsiflexion, plantarflextion) scale of 1-5 (5 = normal)

Coordination: finger to nose, heel to shin, rapid alternating movements

Sensory: safety pin prick/vibration/proprioception/temperature

Gait: stance/stride/ arm swing/tandem walk/steadiness with feet together & eyes  closed

DTR (deep tendon reflexes)

         O

     \   |   /     *note biceps, triceps, brachioradialis, patellar, Achilles reflexes

          |  .          scale of 1 -4 (2 = normal)

     /        \ .

  *annotate with arrows if toes are upgoing or downgoing.

Labs: Na |Cl   |BUN /glucose             \ Hgb /

         K  |CO2|Cr     \                WBC / Hct \ plt

 

        MRI, CT studies, consults, etc.

A/P: “one liner” about pt “Mr Murphy is a 45 y/o right handed WM with a history of ___ who presented with _____. Sometimes, make a comment about their condition if it has changed since admit “s/p (status post) TPA with improvement in left leg weakness”

Problem list (can be done by problems or by systems)

Joe Smith, MS3

346-xxxx (pager #)

DTRs:​Dermatomes:

Biceps = C5, C6​T4 = nipple line

Brachioradialis = C5, C6​T10 = umbilicus

Triceps = C6, C7​L1 = inguinal ligament

Patellar = L4

NO L5 reflex​Caloric eye testing – normal eye movements

Achilles = S1​COWS

​Cold - Opposite

​Warm - Same

MRI

T1 – image looks like brain – ie white matter is white, gray matter darker, CSF black, best for anatomy of brain

T2 – inverse of T1 – white matter is dark, gray matter lighter, CSF white, pathology stand out better (edema has a large water component)

DWI – diffusion weighted images – type of T2 sequence that can identify ischemic areas within minutes of onset

 

Glasgow Coma Score – out of 15

Verbal ​Eye opening​Motor

​6 – follows commands

5 – oriented​​5 – localizes pain

4 – confused​4 – spontaneous​4 – withdraws from pain

3 – inappropriate words​3 – to voice​3 – flexion/decorticate posturing

2 – incomprehensible​2 – to painful stim​2 – extension/decerebrate

1 – no response​1 – no eye opening​1 – no response

 

Causes of delirium – MOVE, STUPID

Metabolic

Oxygen

Vascular

Endocrine/Electrolyte

Seizures

Tumor/Trauma/Temperature

Uremia

Psychogenic

Infection/Intoxication

Drugs/Degenerative disease