A neurology note that localizes before it diagnoses: exact timing, a structured neuro exam, and why the lesion is peripheral rather than central.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Outpatient neurology or urgent care visitPatient: Fictional patient: 42-year-old man, previously healthy
SSubjective
Chief complaint
"The right side of my face is drooping." Noticed on waking at 07:00; last known normal at bedtime, 23:00.
HPI
Weakness worsened over the morning: cannot fully close the right eye; drink leaks from the right side of the mouth. Mild pain behind the right ear yesterday. Sounds seem louder in the right ear; food tastes different. No limb weakness or numbness, slurred speech, vision loss, double vision, vertigo, hearing loss, rash in or around the ear, headache or trauma. No tick bites or travel to Lyme-endemic areas.
Source
Patient.
PMH / meds
No medical history; no diabetes. No medications, no anticoagulants.
OObjective
Vital signs
BP 128/80, HR 72, T 98.2 °F. Fingerstick glucose 96 mg/dL.
Neuro exam
Mental status: alert, oriented, fluent speech, normal comprehension. Cranial nerves: right facial weakness including the forehead (cannot raise the right eyebrow); incomplete right eye closure with visible upward eye roll (Bell phenomenon); flattened right nasolabial fold; mouth droops on the right. Left face normal. Pupils equal and reactive; extraocular movements full; facial sensation intact in all three divisions bilaterally; hearing grossly intact; palate and tongue midline. Motor: 5/5 in all extremities; no pronator drift. Sensory: intact to light touch. Reflexes: 2+ and symmetric. Coordination: finger-to-nose intact. Gait: normal.
Scores
House-Brackmann grade IV.
Imaging / data
Right ear canal and tympanic membrane normal, no vesicles. No parotid mass. No imaging indicated.
AAssessment
Localization
Right peripheral (lower motor neuron) facial nerve. The whole half of the face is weak, including the forehead, which a central lesion such as a stroke would usually spare. Sound sensitivity and taste change place the lesion within the facial canal, proximal to the branches to the stapedius and chorda tympani. No other cranial nerve or limb findings.
Diagnosis / differential
Right Bell's palsy (idiopathic facial nerve palsy), House-Brackmann IV, seen within 72 hours of onset. Less likely: Ramsay Hunt syndrome (no vesicles, hearing loss or vertigo), Lyme disease (no exposure), stroke (forehead involved, no other deficits), parotid tumor (sudden onset, no mass).
PPlan
Diagnostics
No labs or imaging for a typical presentation. MRI if there is no improvement by 3 months or atypical features develop.
Treatment
Prednisone 60 mg by mouth daily for 5 days, then taper by 10 mg a day over 5 days. Given severe weakness, discussed adding an antiviral (small possible benefit); patient chose to add valacyclovir 1 g three times daily for 7 days. Eye protection: artificial tears every 1-2 hours while awake; lubricating ointment and taping the eyelid closed at night; glasses outdoors.
Monitoring
Return immediately for weakness elsewhere, trouble speaking, eye pain, redness or vision change, or a rash in or around the ear.
Follow-up
Recheck in 2 weeks. Refer to a facial nerve specialist if recovery is incomplete at 3 months.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
Last known normal is documented, not just the time the problem was noticed.
The neuro exam is complete and structured, so the normal findings are documented too.
The Assessment localizes the lesion first and explains how the forehead finding separates peripheral from central.
Eye protection gets its own plan: incomplete eye closure is what causes harm.
What students often miss
Last known well for stroke
Documenting a complete neuro exam
Localizing before naming a diagnosis
Neurology SOAP note template
Where in the nervous system is the problem, and when did it start?
SSubjective
Chief complaint
With exact onset.
HPI
Onset (sudden vs gradual), last known well, progression, associated symptoms.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.