Chapter 7: The Nervous System | Nigel Dixon's Chart Note

CHART NOTE

Patient Name: Dixon, Nigel
ID Number: 602DN
Examination Date: April 7, 20xx

SUBJECTIVE
Nigel is now 5 weeks post (after) completion of radiation therapy. He is alert, cooperative, and responsive to questions. He is often tired and sleepy.

OBJECTIVE
Neurological assessment reveals pupils equal, round, and reactive to light. Normal fundoscopic examination (of the inner part of the eye). Extraocular (pertaining to outside the eye) movements still show limitations on the right. The face is symmetric, including eye and lip closure. Nigel continues to have a mild right hemiplegia that is unchanged from his examination 5 weeks ago. Sensory exam is normal to touch, pinprick, and position. Cerebellar examination is normal with a negative Romberg test and a good finger-to-nose test.

ASSESSMENT
The repeated MRA study indicates a diminished brain stem lesion. Sustained clinical improvement over the course of his radiation therapy treatments.

PLAN
Patient will return in 6 weeks for follow-up.