EPILEPSY NEW PATIENT

OVERALL_INSTRUCTIONS

Chief Complaint

Neurology Consult Letter Template

Template

Dear [referring_physician_name], [patient_name] is a [age]-year-old [sex] was reviewed in neurologic consultation for assessment of seizures. As per the referral letter: [Relevant Information from the referral if mentioned.] PCC - INTAKE HISTORY: [Key symptoms of concern: [Key symptoms of concern] Age of first seizure: [The age of first seizure] Seizure frequency: [Seizure frequency] Seizure Risk Factors: [List any positive risk factors such as complications at birth, developmental delays, learning disabilities, febrile seizures, CNS infections, head trauma, family history of epilepsy, brain tumors, strokes, etc.] Seizures/Spells : [List any positive seizure/spell symptoms such as staring spells, amnestic periods, jerking movements, unilateral shaking, isolated aura, fainting, convulsions, unexplained injuries, abnormal sleep behaviors, tongue biting, incontinence, etc.] Additional Neurologic or Systemic Symptoms During Seizures: [List any additional positive symptoms such as headache, neck pain, visual changes, facial numbness/tingling, facial weakness, dizziness, hearing changes, choking, slurred speech, unsteadiness, unilateral weakness, unilateral numbness/tingling, palpitations, trouble breathing, nausea, sweating, etc.] Triggers: [List any positive triggers such as sleep deprivation, alcohol/drug use, new medications, fever, recent head injury, recent neurosurgical procedure, recent travel, exposure to insect bites/animals, significant life stressors, etc.] Review of systems is otherwise noncontributory aside from what is 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, pulling information from transcript, uploaded files, input in notepad/patient visit context.] Previous Antiseizure Medications:[List of Previous Antiseizure Medications] ALLERGIES:[List the patient's allergies. If none, write 'NKDA'.] SOCIAL HISTORY:[Provide relevant details about the patient's social history in concise and point form. for example, Single. No Children. She smoked] Driving:[Provide relevant details about driving status.] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: (if telehealth/video visit, should say "Deferred Telehealth") [Summarize the findings of the neurologic examination. Include the following: VITAL SIGNS: [Summarize the vital signs observed during the examination.] GENERAL: [Describe the general appearance and any notable observations.] MENTAL STATUS: [Detail the patient's mental status, including alertness, orientation, and ability to follow commands.] LANGUAGE: [Provide an assessment of language abilities, including fluency, comprehension, naming, repetition, and spelling.] CRANIAL NERVES: [Evaluate cranial nerve function, including pupil response, visual fields, eye movements, facial sensation and strength, hearing, palate and tongue position, speech clarity, and muscle movements.] MOTOR: [Assess motor function, noting any abnormal movements, weakness, or drift.] COORDINATION: [Examine coordination through tests such as finger-to-nose, heel-to-shin, rapid alternating movements, and Romberg test.] GAIT: [Describe the patient's gait, noting independence and any abnormalities.] SENSORY: [Evaluate sensory function, noting the integrity of primary sensory modalities.] INVESTIGATIONS: [Provide details of any relevant investigations and lab results. 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.