NCS EMG 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 visit]. 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] Aggravating factors: [List relevant Aggravating factor] Alleviating factors: [List relevant Alleviating factor] 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 relevant details about the patient's social history.] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: MENTAL STATUS: [Awake, alert, no acute distress; oriented ×3; follows midline and appendicular commands without difficulty.] MMSE / MOCA: [Provide score if available.] FRONTAL RELEASE SIGNS: [(-) glabellar tap; (-) palmomental reflex; (-) grasp reflex.] LANGUAGE: [Intact fluency and comprehension; naming 3/3; repetition intact; can spell WORLD forwards and backwards; immediate recall 3/3; delayed recall 3/3.] CRANIAL NERVES: [Evaluate pupil response, visual fields, eye movements, facial sensation and strength, hearing, palate and tongue position, speech clarity, and neck muscle strength.] MOTOR: [Examine range of motion, muscle tone, reflexes, and strength in upper and lower extremities. Include specific strength testing results for both right and left sides.] COORDINATION: [Test finger-to-nose, heel-to-shin, and rapid alternating movements; note dysmetria or dysdiadochokinesis.] GAIT: [Observe gait, ability to walk on toes and heels, and perform deep knee bends.] SENSORY: [Check for light touch, pinprick, temperature, and vibration in upper and lower extremities; note any deficits or negative maneuvers.] SCREENING SYSTEMIC EXAMINATION: GENERAL- [Details of general exam, Ex: "Appears well, non-toxic."] VITAL SIGNS – [supine BP HR; standing BP HR] MSK - [No obvious joint deformity or skeletal abnormality] SKIN - [Grossly unremarkable.] INVESTIGATIONS: [List any relevant investigations from uploaded files, notepad, visit context, keep it verbatim. If none, write 'No recent relevant investigations for review.'] ELECTRODIAGNOSTICS [NCS/EMG]: Please contact our office if you require a copy of the test data in tabulated form. The indications, benefits, and potential risks were provided in written format before the appointment and reviewed with the patient. The patient denied a history of C/L-spine surgery or anticoagulant use. The patient tolerated the procedure well. TERMINOLOGY: Distal Latency (DL); Conduction velocity (CV); Amplitude (AMP); SNAP (Sensory Nerve Action Potential); CMAP (Compound Muscle Action Potential); MUAP (Motor Unit Action Potential) TECHNICAL FACTORS: None 1. Sensory Nerve Conduction Studies: [List each sensory study performed and its findings. Example below for reference — modify as applicable.] Right and left median-F2 sensory study [normal/abnormal] Right and left ulnar-F5 sensory study [normal/abnormal] Right and left mixed palmar studies [normal/abnormal] Right and left superficial radial sensory study [normal/abnormal] Right and left medial antebrachial cutaneous sensory study [normal/abnormal] Right and left lateral antebrachial cutaneous sensory study [normal/abnormal] Right and left sural sensory study [normal/abnormal] Right and left superficial peroneal sensory study [normal/abnormal] 2. Motor Nerve Conduction Studies: [List each motor study with nerve, target muscle, and F-wave result. Example below — edit as needed.] Right and left median-APB motor study [normal/abnormal]; F-wave latency [normal/abnormal] Right and left ulnar-ADM motor study [normal/abnormal]; F-wave latency [normal/abnormal] Right and left peroneal-EDB motor study [normal/abnormal]; F-wave latency [normal/abnormal] Right and left tibial-AH motor study [normal/abnormal]; F-wave latency [normal/abnormal] Right and left tibial-TA motor study [normal/abnormal] 3. EMG: [List all muscles tested and findings. Example below — adjust per study.] RIGHT / LEFT FDI, APB, pronator teres, triceps, biceps, deltoid, and C7 paraspinals RIGHT / LEFT tibialis anterior, medial gastrocnemius, vastus lateralis, hamstrings, tensor fascia lata, and L4 paraspinals [All muscles tested with needle EMG were normal / specify abnormal findings such as fibrillation potentials, positive sharp waves, or chronic neurogenic changes.] EDx INTERPRETATION: [Provide a summary of the electrodiagnostic study findings. Include details on whether there is evidence of radiculopathy, plexopathy, peripheral neuropathy, or polyneuropathy. Note any conditions that are not excluded by routine nerve conduction studies.] 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.