NCS EMG REPEAT STUDY

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 diagnoses] Last visit: [Provide the date of the patient's last visit.] Recommendations at Last Assessment: [Copy and paste 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.]] 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: [Summarize the findings of the neurologic examination. Include the following: Last Sinemet Dose: [Specify the time of the last Sinemet dose administered to the patient.] Time Examined: [Indicate the time when the examination was conducted.] MENTAL STATUS: [Describe the patient's mental status, including alertness, orientation, and ability to follow commands.] MMSE / MOCA: [Provide results of the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MOCA) if available.] LANGUAGE: [Detail the patient's language abilities, including fluency, comprehension, naming, repetition, and spelling.] CRANIAL NERVES: [Summarize the examination of cranial nerves, including pupil response, visual fields, eye movements, facial sensation and strength, hearing, and other relevant observations.] MOTOR: [Summarize tone, reflexes, strength, and abnormal movements. Full ROM of C/L-spine; straight leg raise [positive/negative]. Tone [normal/increased/decreased]; no cogwheeling or spasticity. No pronator drift or rebound. DTRs [grade] UE/LE bilaterally; Hoffmann’s [positive/negative]; plantar responses [flexor/extensor]; no ankle clonus. No wasting, fasciculations, or abnormal movements. Strength [5/5 or specify weakness] proximally and distally; no pyramidal, radicular, peripheral nerve, or myopathic pattern. Strength (R/L): UE: SAbd [ ], SAdd [ ], EF [ ], EE [ ], WF [ ], WE [ ], FF [ ], FE [ ], TAbd [ ], FPL [ ] LE: HF [ ], HE [ ], KF [ ], KE [ ], DF [ ], PF [ ], INV [ ], EV [ ], GTE [ ]] COORDINATION: [Provide details on coordination tests such as finger-to-nose, heel-to-shin, and rapid alternating movements.] GAIT: [Summarize the patient's gait, including ability to stand, arm swing, stride length, and any abnormalities.] SENSORY: [Describe the status of primary sensory functions.] SCREENING SYSTEMIC EXAMINATION: GENERAL: [Details of general exam, e.g., “Appears well, non-toxic.”] VITAL SIGNS: [Supine BP HR; standing BP HR] MSK: [No obvious joint deformity or skeletal abnormality.] SKIN: [Grossly unremarkable.] INVESTIGATIONS: [Provide details of any relevant investigations or lab results 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 to the patient prior to the appointment, and a summarized version was reviewed today. The patient had no specific questions regarding testing. The patient denies a history of C/L-spine surgery or anticoagulant use. The patient was agreeable to proceed with the testing and could terminate the study at any time if excessive discomfort occurred. 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: [For each sensory study, specify the nerve and the result. Indicate if the study was normal or if there were any abnormalities.] 2. Motor Nerve Conduction Studies: [For each motor study, specify the nerve, the muscle involved, and the result. Include details about the F-wave latency and whether it was normal or abnormal.] 3. EMG: [List the muscles tested with needle EMG. Indicate if all muscles were normal or if there were any signs of active denervation or chronic neurogenic/myopathic 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 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.