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Neurologist Template

**KURZBEFUND HANDSPRECHSTUNDE**

A professional Neurologist template for healthcare professionals.
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About this template

Looking for a quick and efficient way to document neurological findings? This Kurzbefund Handsprechstunde template is designed for neurologists to quickly record key information during hand consultations. This template allows for the structured documentation of patient history, examination findings, and diagnostic results. It also includes sections for diagnoses, and treatment plans. With Heidi, this template can be automatically populated from your consultation transcript, saving you time and ensuring comprehensive record-keeping. This template is perfect for streamlining your workflow and improving patient care.

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**Anamnese:** - CTS-typische Beschwerden rechts seit 6 Monaten - Gefühlsstörung / Schmerz an Daumen, Zeigefinger und Mittelfinger - Schlechter bei Bewegung und nachts - Keine Verletzungen oder Operationen an dieser Hand - Keine Operationen bzw. Probleme an der Halswirbelsäule - Relevante Vorerkrankungen: Diabetes mellitus **Befund:** - Schmerz / Gefühlsstörung an Daumen, Zeigefinger und Mittelfinger - Thenaratrophie - Schmerz bei festem Faustschluss - Hoffmann-Tinel über Karpaltunnel - Elektrisieren bei Palpation über dem Sulcus Ulnaris **Messergebnis:** - N. medianus: distal motorische Latenz 4.5 ms, Nervenleitgeschwindigkeit motorisch 48 m/s - N. ulnaris: distal motorische Latenz 3.8 ms, Leitgeschwindigkeit über dem Sulcus ulnaris 52 m/s **Diagnose:** - Karpaltunnelsyndrom rechts - Differenzialdiagnosen wie Sehnenansatzreizung **Veranlasst:** - Verordnung: weiche volare Handschiene rechts - Empfehlung: Überweisung - Medikation: Ibuprofen 400mg bei Bedarf - Wiedervorstellung zur weiteren Abklärung
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Specialty

Neurologist

Used

3 times

Type

Note

Last edited

01/09/2025

Created by

Sandra Rückert

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