HEADACHE FOLLOW-UP

OVERALL_INSTRUCTIONS

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 diagnoses] Last visit: [Provide the date of the patient's last visit.] Baseline / Pre-Treatment Headache Days per Month (Average): [Document average number before treatment.] Recommendations at Last Assessment: [Copy the “Plan” from last visit, uploaded files, or visit context.] PCC - INTERVAL HISTORY: Headache Days per Month: [Document the average number of headache days per month since the last visit.] Tolerability / Side-Effect Issues from Last Rx: [Detail any tolerability issues or side effects from the last prescribed medication.] Pregnancy: [Include any updates regarding pregnancy status.] New Neurologic / Medical Symptoms: [Detail new neurologic or medical symptoms, including onset, duration, and character.] Previous Medication Trials for Headaches: [List prior headache medications, including names, dosages, and outcomes.] Medication Coverage: [Provide coverage details, e.g., “Pharmacare.”] 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.] ALLERGIES:[List the patient's allergies. If none, write 'NKDA'.] SOCIAL HISTORY:[Provide relevant details about the patient's social history, driving status] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION:[List the findings of the neurologic examination verbatim, include all pertinent negative/positive, Include the following: (if it's telehealth/video visit, say "Deferred - telehealth") 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: [List any relevant investigations or 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]. PLAN:[plan] Thank you for involving me in the care of this patient. Collaborative assessment performed by [collaborator names] and Dr. N. Randhawa.