Neurology Student Case Report Template
Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.
- 1General patient data
Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."
- 2Complaints
Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.
- 3History of the present illness (Anamnesis morbi)
Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.
- 4Past Medical History (Anamnesis vitae)
- Brief biographical data, living conditions, and dietary habits
Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.
- Occupational history
Profession, length of service, working conditions, occupational hazards (without naming the organization).
- Past medical history, surgeries, injuries
Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).
- Bad habits
Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.
- Medication history
Regular medications taken by the patient (name, dose, frequency).
- Allergic history
Drug, food, and household allergen intolerance; type of reaction.
- Epidemiological history
Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.
- Family history
First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).
- Obstetric and gynecological history
For women: menarche, menstrual cycle characteristics, menopause, pregnancies/childbirth/abortions.
- Insurance history
Certificate of incapacity for work (duration), disability group.
- 5Objective examination (Status praesens objectivus)
- General physical examination
General condition, level of consciousness, body position, physique, body type, height, body weight, BMI, body temperature; skin and visible mucous membranes, subcutaneous adipose tissue, edema, lymph nodes, muscles, bones, joints.
- Respiratory system
Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.
- Cardiovascular system
Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.
- Digestive system
Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.
- Urinary system
Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.
- Endocrine system
Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.
- 6Neurological Status (Status Neurologicus)
- Consciousness and Higher Mental Functions
Level of consciousness (GCS), orientation, speech (aphasia, dysarthria), praxis, gnosia, memory.
- Meningeal signs
Nuchal rigidity, Kernig's and Brudzinski's signs.
- Cranial Nerves (Pairs I–XII)
By pairs: olfaction, vision and visual fields, extraocular nerves (pupils, reactions, eye movements, nystagmus), trigeminal, facial, hearing, bulbar group, accessory, hypoglossal.
- Motor Sphere
Range of motion, muscle strength (by groups in points), tone, trophics, hyperkinesia.
- Reflex Sphere
Tendon and periosteal reflexes (symmetry), abdominal, pathological plantar and palm signs, oral automaticity reflexes.
- Sensory function
Superficial and deep sensation, type and area of impairment, tension signs.
- Coordination of Movements
Finger-to-nose and heel-to-shin tests, Romberg's sign, gait, adiadochokinesia.
- Autonomic Nervous System and Pelvic Functions
Perspiration, dermographism, orthostatic reactions, pelvic organ functions.
- 7Topical Diagnosis and Its Justification
Determine the level and side of the nervous system lesion based on identified neurological syndromes.
- 8Preliminary diagnosis and its rationale
Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.
- 9Examination plan
Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).
- 10Results of laboratory and instrumental studies
All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".
- 11Differential diagnosis
At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).
- 12Clinical diagnosis and its rationale
Clinical Diagnosis in Neurological Format: nosological, topical, and syndromal components, severity, course; ICD-10 code; comorbid conditions; justification.
- 13Etiology and pathogenesis
Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).
- 14Treatment and its rationale
Regime, diet (table), non-pharmacological treatment, pharmacotherapy: drug (INN), dose, route, frequency, duration, and justification with reference to clinical guidelines; At the end: prescriptions in Latin (Rp.: … D. S. …) for 2–3 main drugs.
- 15Observation notes
prescriptions).
- 16Stage (discharge) epicrisis
Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.
- 17Prognosis and recommendations
Prognosis for Life, Recovery, and Work Capacity (with justification); discharge recommendations and follow-up care according to Clinical Guidelines. Rehabilitation potential.
- 18References
formatted according to GOST R 7.0.100-2018.
Neurology Case Report Template: Most Rigorously Checked Sections
Complaints, anamnesis, and somatic status are written similarly to internal medicine. The case report is evaluated based on two main parts: the neurological status and the logic of the diagnosis. Diagnosis in neurology is established in three steps: syndromes, then topical diagnosis (location of the lesion), followed by nosological diagnosis (the underlying pathological process).
How to Describe Neurological Status
- Consciousness and Higher Mental Functions: level of consciousness (evaluated using the Glasgow Coma Scale in case of impairment), orientation, speech, praxis, gnosia, memory.
- Meningeal Signs: nuchal rigidity, Kernig's and Brudzinski's signs.
- Cranial Nerves I to XII in order and with side indication: pupils and their reaction to light, extraocular movements, nystagmus, facial sensation, facial musculature (central or peripheral paresis of the VII nerve), swallowing, phonation, tongue position.
- Motor Sphere: range of motion, muscle strength in points by muscle groups, tone (spasticity, rigidity, hypotonia), tendon and periosteal reflexes comparing sides, abdominal reflexes, pathological plantar signs (Babinski, Rossolimo, and others), clonus.
- Sensation: superficial and deep, type of impairment (peripheral, radicular, segmental, conduction, cortical) and its boundaries.
- Coordination: finger-to-nose and heel-to-shin tests, Romberg's sign, gait, diadochokinesia.
- Autonomic Nervous System and Pelvic Organ Functions.
Topical Diagnosis
This is the section where cases are rejected most frequently. You need to gather the syndromes and demonstrate why the lesion is localized precisely there. Central paresis of the arm and leg on the side contralateral to the lesion, combined with central paresis of the VII and XII nerves on the same side, indicates a hemispheric lesion. An alternating syndrome (cranial nerve affected on the side of the lesion, hemiparesis contralaterally) points to the brainstem. Flaccid paresis with absent reflexes and sensation in a radicular or nerve distribution points to a peripheral level. Aphasia in a right-handed person localizes the lesion to the left hemisphere. The topical diagnosis must explain all identified symptoms, not just some of them.
Scales and Disease Period
For stroke, expect NIHSS upon admission and dynamically, the modified Rankin Scale, and the Barthel Index for self-care assessment; for impaired consciousness, the Glasgow Coma Scale. Calculations can be easily checked in the clinical scales section. The period of ischemic stroke is indicated according to current clinical guidelines: hyperacute (first 3 days), acute (up to 28 days), early recovery (up to 6 months).
Neurology Case Report Example: Ischemic Stroke
Fragments of a model case report. The patient is fictional, and the data are for educational purposes.
Neurological Status (Fragment)
Patient N., 67 years old, right-handed, 5th day of the disease. Consciousness is clear, 15 points on the Glasgow Coma Scale. No meningeal signs. Pupils D = S, direct light reflex is brisk. Right nasolabial fold is flattened, forehead wrinkles symmetrically. Tongue deviates to the right upon protrusion, no atrophy or fasciculations. Motor aphasia, comprehension of spoken speech is preserved. Strength in the right arm is 3 points, right leg 4 points, left limbs 5 points. Tendon reflexes D > S, positive Babinski sign on the right. Right-sided hemihypesthesia. Performs the finger-to-nose test confidently on the left; the right side cannot be assessed due to paresis. NIHSS on admission was 8 points, on the 5th day 6 points.
Topical Diagnosis
Syndromes: right-sided central hemiparesis predominantly affecting the arm, central paresis of the VII and XII cranial nerves on the right, right-sided hemihypesthesia, motor aphasia. Central hemiparesis combined with central paresis of the VII and XII cranial nerves on the same side indicates a lesion in the left hemisphere. The predominance of paresis in the face and arm over the leg and motor aphasia in a right-handed individual point to the frontoparietal regions of the left hemisphere, i.e., the basin of the left middle cerebral artery. Due to the aphasia, an isolated lacunar infarct in the internal capsule is unlikely: the lesion involves the cortex.
Clinical Diagnosis
Primary Disease: Ischemic stroke in the basin of the left middle cerebral artery (I63.4), cardioembolic pathogenetic subtype, acute period. Right-sided hemiparesis (arm 3 points, leg 4 points), right-sided hemihypesthesia, motor aphasia. NIHSS 6 points.
Background Conditions: Permanent atrial fibrillation. Stage III hypertension, risk 4 (very high).
The subtype was established according to TOAST criteria: permanent atrial fibrillation as a source of embolism, no hemodynamically significant stenosis of brachiocephalic arteries, and a cortico-subcortical lesion on MRI. Therefore, code I63.4 (cerebral infarction due to embolism of cerebral arteries) is used rather than I63.3 or I63.5.
Examination Plan (Key Points)
- Brain CT upon admission (hemorrhage excluded) and CT angiography; MRI with DWI sequence to confirm the lesion.
- Duplex scanning of brachiocephalic arteries.
- ECG, 24-hour Holter ECG monitoring, echocardiography.
- Complete blood count and blood biochemistry, glucose, lipid panel, coagulogram.
- Screening swallowing assessment prior to initiating oral feeding.
Reperfusion therapy was not performed: the patient was admitted 12 hours after symptom onset, and CT angiography showed no large vessel occlusion. For secondary prevention in atrial fibrillation, an anticoagulant is prescribed; the timing of initiation is chosen based on infarct size and the risk of hemorrhagic transformation, as outlined in the clinical guidelines «Ischemic Stroke and Transient Ischemic Attack» (see clinical guidelines section).
Common Mistakes in Neurology Case Reports
- Neurological status written as a template or using the phrase «no focal neurological deficits», even though the patient has paresis.
- Cranial nerves described out of order, some pairs omitted, failure to distinguish between central and peripheral paresis of the VII cranial nerve.
- Muscle strength recorded without point values, reflexes compared without noting side differences.
- Failure to define the type of sensory impairment and its boundaries.
- No topical diagnosis is made, or it is substituted by a nosological one; the topography explains only part of the symptoms.
- Confusing the side of the lesion and the side of the symptoms: right-sided hemiparesis with a hemispheric lesion indicates damage to the left hemisphere.
- Stroke is formulated without the vascular territory, pathogenetic subtype, period, and scale scores.
- After CT or MRI, the clinical diagnosis still says "CVA": this is a working diagnosis prior to neuroimaging, not the final one.
- Including the patient's real full name, date of birth, or address in the demographic section. This violates medical confidentiality (Article 13 of Federal Law 323-FZ) and personal data regulations (Federal Law 152-FZ): write anonymized data.
Compile your own neurology case history
The patient can be simulated for a specific condition, or you can upload your own clinical notes (text, handwritten photos, audio). Cross-checked with clinical guidelines, ICD-10 coding, and export to Word and PDF. 2 case histories per month for free.
Frequently asked questions
How to describe neurological status in a case history?
Go top-to-bottom in a fixed order: consciousness and higher functions, meningeal signs, cranial nerves I through XII, motor system (muscle strength in points, tone, reflexes, pathological signs), sensory system, coordination, autonomic system, and pelvic functions. Indicate the side for each finding. If there are no abnormalities, state so for each item rather than using a single phrase for the entire status.
What is the neurology case history outline?
General section as in internal medicine, followed by detailed neurological status, syndromic and topical diagnosis, preliminary diagnosis, investigation plan, clinical diagnosis, treatment, and progress notes. The generator compiles the case history according to the neurology outline, but if your department has its own outline, you can upload its template.
How to make a topical diagnosis?
First, identify the syndromes (central or peripheral paresis, type of sensory disturbance, affected cranial nerves, cerebellar disorders). Then find the level where a single lesion explains them all: cortex, internal capsule, brainstem, spinal cord, nerve root, or nerve. Determine the side based on pathway decussation: a hemispheric lesion causes symptoms on the opposite side of the body.
Where can I find an example of a neurology case history?
A model excerpt for ischemic stroke is analyzed above: neurological status, topography, and diagnosis formulation with the ICD-10 code. The generator will compile a full case history for the required disease from your bedside teaching notes or for the disease alone; in the latter case, the patient is simulated. Missing data are marked as "not specified".
Which scales should be indicated in a neurology case history?
For a stroke, typically the NIHSS upon admission and over time, the modified Rankin scale, the Barthel index for self-care assessment, and the Glasgow Coma Scale for impaired consciousness. It is best to check with your department which scales are mandatory. You can verify the score calculations in the clinical scales section.
Can an AI write a neurology case history?
A draft can be created: the generator will cross-check the diagnosis and treatment with the Russian Ministry of Health clinical guidelines, assign the ICD-10 code, write prescriptions in Latin for 2–3 main medications, and provide a list of references. However, you will have to explain the topography during your defense, so figure out the logic yourself. Do not include real names or other patient data in your bedside notes. Two case histories per month are free on any account, and five more are added on the "Maximum" plan.
Case histories for other subjects
How the generator works and how to check its output: case history with AI. All tools: AI for medical professionals.