MOVEMENT DISORDERS 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 a movement disorder. As per the referral letter: [Relevant Information from the referral if mentioned.] PCC - INTAKE HISTORY: [Key symptoms of concern: [List relevant key symptoms of concern] Date of symptom onset: [date of symptom onset] Memory / Cognitive Symptoms: [Provide a detailed list of memory and cognitive symptoms experienced by the patient. Include short-term and long-term memory difficulties, issues with names and recognizing familiar faces, dangerous behaviors, disorganization, multitasking challenges, language difficulties, disorientation, driving difficulties, confusional episodes, hallucinations, and sleep disturbances.] Associated Neurologic Symptoms: [Detail the associated neurologic symptoms. Include headaches, neck pain, visual changes, numbness or tingling on either side of the face, facial weakness, hearing loss, tinnitus, dizziness, choking, drooling, cognitive and sleep changes, mood or personality changes, language changes, limb weakness, incoordination, balance difficulties, reliance on mobility aids, falls, back pain, incontinence, seizures, abnormal movements, stiffness, handwriting changes, and loss of smell.] Associated Systemic or Constitutional Symptoms: [List any systemic or constitutional symptoms. Include chest pain, palpitations, dizziness upon standing, fainting, breathing difficulties, gastrointestinal issues, urinary symptoms, joint swelling, rashes, weight loss, night sweats, fatigue, and any other general medical symptoms.] Potential Triggers at Symptom Onset: [Identify potential triggers at the onset of symptoms. Include head or neck injuries, back injuries, illnesses, medication changes, surgeries, vaccinations, travel, tick bites, life stressors, or any other potential causes.] 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, 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 details on smoking habits, alcohol consumption, and drug use, including frequency and last use. Include exercise routine details. Add sections for marital status, children, and profession. Include sections for ADLs (Activities of Daily Living), IADLs (Instrumental Activities of Daily Living), driving, languages spoken, and highest education.] FAMILY HISTORY: [Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: [Write the following examination as it is, do not change anything: Last Sinemet Dose - Time Examined - MENTAL STATUS - Awake, alert, no acute distress; oriented x 3; follows midline and appendicular commands without difficulty. MMSE / MOCA - LANGUAGE - Intact fluency, comprehension, naming 3/3, repetition, can spell WORLD forwards and backwards. CRANIAL NERVES - PERRL, no RAPD; visual fields full; EOM full with no nystamgus or reports of diplopia; saccades and pursuit normal; no ptosis/Horner's; facial sensation intact and symmetric; facial strength symmetric; hearing intact to conversation; palate and tongue midline; no dysarthria or hypophonia; SCM and trapezius muscles full strength. No hypomimia / masked facies. Normal blink rate. MOTOR - Tone normal - no cogwheeling or spasticity; no axial or appendicular rigidity even with activation; no pronator or finger drift; no rebound; DTRs 2+ UE and LE bilaterally, Hoffmann's negative bilaterally, plantar responses flexor bilaterally, no ankle clonus; no abnormal movements; no bradykinesis on finger or foot tapping; strength 5/5 in all four extremities both proximally and distally - no pyramidal distribution of weakness. COORDINATION - Normal finger-to-nose, heel-to-shin, rapid alternating and fine finger movements – no convincing dysmetria or dysdiadochokinesis; Romberg negative; tandem gait steady. GAIT – Normal. Can stand from a seated position without using arms. Normal arm swing and stride length. No stooped posture. No festination. No turn en bloc. Negative pull test. SENSORY - Intact primary sensory modalities. No convincing sensory deficit. UPDRS:] SCREENING SYSTEMIC EXAMINATION: [Write the following examination as it is, do not change anything: GENERAL- Appears well, non-toxic. POSTURAL VITAL SIGNS – supine BP HR ; standing BP HR] INVESTIGATIONS:[Provide details of any relevant investigations, 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.