GENERAL NEURO 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 in neurologic reassessment of [symptom]. Diagnosis: [List all relevant diagnosis] Last reviewed: [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: [Current status of neurologic symptoms: [Detail the current status of any neurologic symptoms, specifying any changes or stability in symptoms.] New neurologic symptoms: [Detail any new neurologic symptoms, specifying onset, duration, and character.] General medical updates: [Include any major medical updates such as 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.] Driving:[Provide relevant details about driving status.] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: (if it's telehealth/video visit, say "Deferred - telehealth") [Summarize the findings of the neurologic examination. Include all pertinent negative/positive like the following examples: 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.] For Example: VITAL SIGNS – GENERAL – Appears well, nontoxic. MENTAL STATUS – Awake, alert, no acute distress. Oriented x 3. Follows midline and appendicular commands without difficulty. LANGUAGE – Intact fluency, comprehension, naming 3/3, repetition, can spell WORLD forwards / backwards. CRANIAL NERVES – PERRL, VF full, EOM full, facial sensation intact and symmetric, facial strength intact and symmetric, hearing intact to conversation, palate and tongue midline, no dysarthria, SCM and trapezius muscles move symmetrically. MOTOR – No pronator drift, no abnormal movements, no lateralizing weakness. COORDINATION – Normal finger-to-nose, heel-to-shin, rapid alternating and fine finger movements; Romberg negative; tandem gait steady. GAIT – Normal, independent. SENSORY – Intact primary sensory modalities.] INVESTIGATIONS:[Copy and paste details of any relevant investigations and lab results from uploaded files and visit context. 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. The physicians and their clinical care team respectfully acknowledge that we are located and operate on the unceded territories of the xwməθkwəyəm (Musqueam), Sḵwxwúʔmesh (Squamish), səlilwətaɬ (Tsleil-Waututh), and Kwikwetlem Nationsfrom