COGNITIVE FOLLOW-UP

OVERALL_INSTRUCTIONS

Chief Complaint

Neurology Consult Letter Template

Template

Dear [referring_physician_name], [patient_name] is a [age]-year-old [sex] who was reviewed for neurologic reassessment of [symptom]. Diagnosis: [List all relevant diagnosis] Last Visit: [Provide the date of the patient's last visit.] Recommendations at Last Assessment: [Summarize the "Plan" provided at the last visits, information in uploaded files and Notepad, patient visit context.] PCC - INTERVAL HISTORY: [[Provide updates on the patient's condition since the last visit. Include any new neurologic symptoms or Major Medical Updates.] - New neurologic symptoms: [Details include specifying onset, duration, and character] - Major medical updates: [Details include new diagnoses, hospitalizations, or changes in treatment plans.]] PAST MEDICAL HISTORY:[List the patient's past medical history.] MEDICATIONS:[List the patient's current medications.] ALLERGIES:[List the patient's allergies. If none, write 'NKDA'.] SOCIAL HISTORY:[Provide relevant details about the patient's social history.] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: [Summarize the findings of the neurologic examination. including all pertinent negatives/positive. Include the following: Mental Status: [Description of alertness, orientation, and command following] Cognitive Tests: [Results of MMSE/MOCA if performed] Frontal Release Signs: [Presence or absence of glabellar tap, palmomental reflex, grasp reflex] Language: [Assessment of fluency, comprehension, naming, repetition, recall] Cranial Nerves: [Evaluation of pupil response, visual fields, eye movements, facial sensation and strength, hearing, palate and tongue position, speech] Motor: [Assessment of tone, rigidity, reflexes, strength, and abnormal movements] Coordination: [Evaluation of finger-to-nose, heel-to-shin, rapid alternating movements, Romberg test, tandem gait] Gait: [Description of gait, ability to stand, arm swing, stride length, posture] Sensory: [Assessment of primary sensory modalities and any deficits] SCREENING SYSTEMIC EXAMINATION: GENERAL- [Details of general exam, Ex: "Appears well, non-toxic."] VITAL SIGNS – [Vital signs details include BP, HR] INVESTIGATIONS:[Provide details of any relevant investigations and lab results from transcript and draft encounters. If none, write 'No recent relevant investigations for review.'] IMPRESSION: [patient_name] is a [age]-year-old [sex] with a history of [diagnosis]. DIAGNOSIS: [List all relevant DIAGNOSIS] PLAN: [plan] Thank you for involving me in the care of this patient. Collaborative assessment performed by [collaborator_names] and Dr. N. Randhawa.