Neuro Dept

The Four Major Areas of the Medical Record (SOAP)

  • S-Subjective: Why did this patient come into the clinic today? Obtained from the patient’s perspective, NOT the physician’s

    • History of Present Illness (HPI) 

      • The HPI explains the patient’s chief complaint (cc). There are 7 key descriptors of the cc. 

        • Location (ex. Pain in the right upper extremity (RUE))

        • Quality (ex. Pain is dull, stabbing, burning, etc)

        • Severity (ex. 1-10 rating, mild, moderate, severe)

        • Timing/duration (ex. Pain is improving, chronic; lasts for 2 weeks, intermittent)

        • Context (ex. Pain occurred after lifting heavy object)

        • Associated signs and symptoms (anything accompanying cc ex. Numbness in RUE along with loss of function) 

Subjective movement disorder example:  (Intro-gives clinician a snapshot of the patient’s cc.) Sally Smith is a 56 year old female with a history of Essential Tremor (ET) who presents to the neurosurgery clinic for DBS/HIFU consideration to treat her bilateral hand tremor, R>L. (Description/Context- describe the cc further, quality, severity, modifying factors, previous treatment) Mrs. Smith has had tremor since her early 30’s, and has gradually crescendoed overtime. The patient reports that her tremor is worse in the mornings and when she is stressed. She also reports that her tremors improve with alcohol consumption. She has previously tried Sinemet 50 mg QID in which it has not helped her tremor significantly. (Associated symptoms- includes any additional symptoms or lack thereof or history of pertinent info- usually kidney, heart, lung issues). Additionally, the patient has had frequent falls within the last month due to feeling unbalanced. Patient denies bladder/bowel incontinence, syncope, and numbness. PMH is significant for Afib, DM, HTN. Surgical history includes pacemaker placement in which she is now on Eliquis. 

  • O-Objective: What did the clinician find on their evaluation? What occurred during the visit to lead them to their diagnosis? Obtained from the physician’s perspective, NOT the patient’s

    • If there was a significant finding, (ex. tenderness), I typically bold the text. 

  • A- Assessment: Differential diagnoses, diagnostic tests ordered (and why), the amount of information that must be obtained, reviewed, and analyzed through medical records and specialist physician consults, management options and plans while in the department

  • P-Plan: Documentation of a final diagnosis (if applicable), if there is more than one diagnosis-list them. Include pertinent PMH and any anticoagulants/antiplatelets. 
























Basic Terminology 

(bolded=more frequently seen/used words, blue=common surgeries, red=common disorders, conditions with patients)

  • Anterior cervical discectomy and fusion (ACDF): procedure that treats conditions in the cervical spine, or neck bones, by decompressing the spinal cord and nerve roots, and then fusing the vertebrae

  • Anterior Lumbar Interbody Fusion (ALIF): procedure, type of fusion 

  • ambulate: to walk from place to place

  • Akinesia: loss or impairment of voluntary movement

  • bradycardia: slow heart rate (HR less than 60 bpm)

  • Bradykinesia: slow movement (usually in PD patients)

  • cardiomegaly: enlarged heart

  • cholecystitis: inflammation of the cholecyst (gallbladder)

  • COPD: Chronic obstructive Pulmonary disease commonly seen

  • Cerebrovascular Accident (CVA): "stroke", lack of blood supply to the brain causing brain damage

  • Degenerative disc disease (DDD): syndrome in which age-related wear and tear on a spinal disc causes low back pain.

  • Diabetes mellitus (DM)

  • Diaphoresis: sweating

  • Discectomy: procedure that removes abnormal disc material from the spine that presses on a nerve root or spinal cord.

  • Deep brain Stimulation (DBS) and HiFU (high intensity focused ultrasound): used for treating tremor in essential tremor patients (ET) or Parkinsonian patients. 

  • deep vein thrombosis (DVT):  a blood dot in a deep vein, most often extremity

  • dyspnea: problems with breathing

  • dysuria: painful urination

  • ecchymosis: a bruise

  •  edema: swelling

  • Epistaxis: nose bleed

  • Erythema, erythematous: redness/red- Dr. Marsh loves using this. 

  • febrile: elevated body temperature, fever, indicative of infection

  • Headache (HA)

  • hematemesis: very large amounts of blood in the vomit

  • hematuria: very large amounts of blood in urine

  • hemoptysis: coughing up very large amounts of blood

  • hepatomegaly: enlarged Liver

  • Hypertension (HTN)

  • hypoxia: low O2 saturation of the body, not enough oxygen in the blood

  • infarct: area of dead tissue after a lack of blood supply

  • ischemia: lack of blood supply

  • Laminectomy: procedure that removes part or all of the lamina, or roof, of a vertebra to relieve pressure on the spinal cord or nerve roots. 

  • Loss of consciousness (LOC)

  • Microvascular Decompression (MVD): surgery to help trigeminal neuralgia patients

  • Myocardial infarction (MI) death of cardiac muscle due to ischemia

  • Myalgia: muscular pain, “muscle aches”--could be used to describe pain in back (ex. Paraspinal myalgia in lower back)

  • Normal Pressure Hydrocephalus (NPH): See Dr. Konrad info 

  • Posterior spinal fusion (PSF)

  • Pulmonary embolism (PE): blockin of pulmonary artery due to blood clot

  • rales : “crackles”, wet crackling noise in lungs

  • Rhinorrhea: clear nasal discharge, “runny nose”--will typically be seen in Dr. Lewis’s clinic after a tumor resection if he goes through the nose.

  • Spinal Stenosis: narrowing of the spinal canal or neural foramen  

  • Subarachnoid hemorrhage (SAH): seen with trauma cases, blood on brain after injury to head.

  • Subdural Hematoma (SDH): seen with trauma cases, blood on brain after injury to head

  • Supine: laying on back (“during suPINE, you lay on your SPINE”)

  • Prone: laying on your stomach

  • Shortness of breath (SOB)

  • Syncope: “passing out”, loss of consciousness or fainting. 

  • Tachycardia: increased heart rate (HR greater than 100 bpm)

  • Tachypnea: increased breathing rate

  • Transient ischemic attack (TIA): minor stroke where neurological function is regained quickly with time. 

  • Trigeminal neuralgia: electric shock pain in a patient's face that can be aggravated with wind blowing on their face, touch, chewing. Etc. (Seen mostly in Dr. Konrad’s clinic)




Anatomy 

Anatomical positional terms: THESE ARE PERTINENT TO MEMORIZE.

  • Spinal vertebrae: It is important to know how many vertebrae are in each section of the spine. The one mnemonic that helped me: cervical is the first section (the first meal of the day, breakfast, is eaten at 7 AM) thoracic is the second section (the second meal of the day, lunch, is eaten at 12 PM), lumbar is the third section (the third meal of the day, dinner, is eaten at 5 PM)- where the times represent how many vertebrae there are.


  • Dermatomes: These are important to help describe the distribution of pain or numbness. A lot of times I use them to describe trigeminal neuralgia pain with Dr. Konrad. (Ex. trigeminal pain in the V2/V3 distribution). 





Basic anatomy of the brain– I would memorize where each section is (occipital lobe is posterior) because this could help you describe where headache pain is or if a patient has occipital nerve neuralgia you could pick up on it quickly and efficiently. This is also helpful when the clinician wants you to describe something in a patient’s imaging. 

The thalamus is also an important topic for the Movement Disorders clinic to treat tremor patients. The thalamus can be subdivided into the subthalamic nucleus (STN) or ventral intermediate nucleus  (ViM). Along with the globus pallidus internus (GPi), but that is located in the basal ganglia. You don’t necessarily need to know the function of each subsection, just be familiar with them.