COGNITIVE NEW PATIENT

OVERALL_INSTRUCTIONS

Template

Dear [referring_physician_name], [patient_name] is a [age]-year-old [sex] who was reviewed for neurologic consultation for assessment of [symptom]. As per the referral letter: [Relevant Information from the referral if mentioned.] PCC - INTAKE HISTORY: [Key symptoms of concerns: [key symptoms of concerns] [Date of symptom onset: [date of symptom onset] Memory & Cognitive Symptoms: [List any difficulties with short-term or long-term memory, recognizing faces, dangerous behaviors, organization, multitasking, language, orientation, driving, confusional episodes, hallucinations, sleep disturbances, or any other cognitive issues.] Associated Neurologic Symptoms: [Include any headaches, neck or back pain, visual or auditory changes, numbness, weakness, speech or cognitive changes, sleep or mood changes, balance issues, seizures, abnormal movements, or any other neurologic symptoms.] Associated Systemic or Constitutional Symptoms: [Detail any chest pain, palpitations, dizziness, breathing difficulties, gastrointestinal or urinary symptoms, joint swelling, rashes, weight changes, night sweats, fatigue, or any other systemic symptoms.] Potential Triggers at Symptom Onset: [Identify any head or neck injuries, illnesses, medication changes, surgeries, travel, tick bites, stressors, or any other potential triggers.] Previous Treatments: [Include any previous treatments the patient has undergone related to these symptoms.] Review of systems is otherwise noncontributory aside from that described above and in the past medical history:] 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. for example, ADLs: Independent. IADLs: Independent] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: 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:[List details of any relevant investigations and lab results. keep it verbatim from uploaded files 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.