Neurologic system
Neurologic system
Create a neuro-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and a treatment plan in a full SOAP note format. Use a neuro-related CC that a patient would present within a primary care setting (i.e. no emergency room or ICU type complaints). Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc..
Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citation, and references. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow-up).
The ROS and physical exam in your document should be written up as they would be for a problem-focused visit. The neurological part of the physical exam write-up should be a comprehensive write-up, including everything you assessed in your recording. The neuro write-up is usually a full page or page and a half when done well.