PARKINSONS FOLLOW-UP

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 Parkinson's disease. Last reviewed: [Provide the date of the patient's last visit.] Date of symptom onset: [Specify the relevant date of symptom onset.] Date of diagnosis: [List all relevant diagnoses] Recommendations at Last Assessment: [Summarize the "Plan" provided at the last visits, information in uploaded files and Notepad, patient visit context.] PCC - INTERVAL HISTORY: Parkinson’s Symptom Review: [List each symptom in bullet point clearly, including stiffness, freezing episodes, wearing off, falls, need for mobility aids, tremor, dyskinesias, dysphagia/drooling, cognitive changes, hallucinations, sleep disturbance, and independence with ADLs and IADLs.] For Example: Parkinson’s Symptom Review: - Stiffness - Freezing episodes - Wearing off - Falls - Need for mobility aids - Tremor - Dyskinesias - Dysphagia / Drooling - Cognitive changes - Hallucinations - Sleep disturbance - Independent with ADLs - Independent with IADLs Additional / new neurologic symptoms: [List any additional or new neurologic symptoms] Additional / new general medical symptoms: [List any additional or new general medical symptoms] Driving: [Describe the patient's driving status, including any restrictions or concerns] 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.] ALLERGIES:[List the patient's allergies. If none, write 'NKDA'.] SOCIAL HISTORY: [Provide relevant details about the patient's social history. For example: ADLs – Independent. IADLs – Independent.] FAMILY HISTORY:[Provide relevant details about the patient's family history.] FOCUSED NEUROLOGIC EXAMINATION: If it's telehealth/video visit, say "Deferred - telehealth" 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: [Describe motor function, including tone, rigidity, reflexes, strength, and any abnormal movements.] 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, Ex: "Appears well, non-toxic."] POSTURAL VITAL SIGNS – [supine BP HR; standing BP HR] INVESTIGATIONS:[Copy and paste details of any relevant investigations, lab results from uploaded files, visit context, transcript. 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.