GENERAL NEURO NEW PATIENT

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 consultation for assessment of [Reason of the visit]. PCC - INTAKE HISTORY: Key symptoms of concern: [Provide a detailed list of the primary symptoms the patient is experiencing.] Date of symptom onset: [Specify the date when the symptoms first appeared.] Aggravating factors: [List any factors that worsen the symptoms.] Alleviating factors: [List any factors that relieve the symptoms.] Associated Neurologic Symptoms: [Include any related neurologic symptoms — headaches, neck or back pain, visual changes, facial numbness or weakness, hearing loss, tinnitus, dizziness, vertigo, choking, drooling, speech or language changes, cognitive or mood changes, weakness or numbness in limbs, incoordination, balance problems, falls, need for mobility aids, seizures, abnormal movements, stiffness, handwriting changes, loss of smell, or note if none.] Associated Systemic / Constitutional Symptoms: [Include systemic or constitutional symptoms — chest pain, palpitations, orthostatic dizziness, fainting, shortness of breath, gastrointestinal upset, urinary changes, joint swelling, rashes, weight loss, night sweats, fatigue, or note if none.] Potential Triggers at Symptom Onset: [List possible triggers — head, neck, or back injury; limb trauma; infection or fever; medication changes; surgery; vaccination; travel; tick bite; stressor; or note if none identified.] Any Treatments: [Describe any treatments that have been tried.] 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, pulling information from transcript, uploaded files, or visit context.] ALLERGIES: [List the patient's allergies. If none, write “NKDA.”] SOCIAL HISTORY: [Provide relevant social details — occupation, habits, living situation, etc.] DRIVING: [Provide relevant details about driving status.] FAMILY HISTORY: [Provide relevant details about family medical history.] FOCUSED NEUROLOGIC EXAMINATION: (If telehealth/video visit, write “Deferred – telehealth.”) [List the findings of the neurologic examination from uploaded files verbatim. 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.] 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 verbatim, 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.