Neurology Admission H&P (Inpatient)

Date/Time: [Encounter date, exact time, and time zone] (Use absolute timestamps; include time zone when time-sensitive.)

Author: [Author name, role, and service/team]

Location: [ED / ICU / Floor]; [Inpatient / Observation]

History Source: [Patient / Family / EMS / Outside records / Chart] — [reliable / limited / unobtainable] (State limitation reason if not reliable, e.g., aphasia, encephalopathy, sedation, no collateral. Never leave blank.)

Chief Concern / Reason for Admission

[One-line summary combining patient-reported concern and clinical indication for admission; include transfer source and reason if applicable]

History of Present Illness

[Baseline neurologic and functional status prior to current event: ADL independence, mobility and assistive devices, baseline cognition/communication, prior focal deficits]

[Last known normal or symptom onset with exact date, time, and source/observer] (If unknown, state discovery time and by whom. Write "Unknown—reason" and identify pending collateral if truly unknown. Do not infer.)

[Chronologic narrative of symptom evolution with embedded timestamps: onset tempo, fluctuation, progression, triggers, associated neurologic and systemic symptoms; syndrome-specific descriptors as relevant; pre-hospital and ED course including treatments given, response, and critical results with timestamps; pertinent negatives narrowing the differential] (Attribute facts to source when not from patient. State "Unknown—reason" for missing information. Do not introduce localization or diagnostic conclusions here.)

Relevant Background

Past Neurologic History: [Prior cerebrovascular events with dates and residuals; epilepsy/seizures; CNS infection; tumor; demyelinating disease; headaches; neuromuscular/spine disorders; cognitive disorders; prior neuro diagnostics with dates; neurosurgical or endovascular interventions]

Past Medical/Surgical History: [Comorbidities influencing risk/differential: atrial fibrillation, anticoagulation indication, diabetes, malignancy, immunocompromise, ESRD, cirrhosis, OSA, substance use; surgical history only when relevant to current decisions]

Medications: [Home medication list highlighting time-critical agents with last doses: anticoagulants, antiplatelets, antiseizure meds, sedatives, insulin; recently stopped meds with reason; ED medications given with timestamps when relevant] (If incomplete, state "Home med list incomplete—awaiting pharmacy verification.")

Allergies: [Drug allergies with reaction type and severity; distinguish true allergy vs intolerance]

Family History: [Epilepsy, aneurysm/SAH, early stroke, hypercoagulable disorders, neurodegenerative disease] (Include only if it changes the differential; omit section if noncontributory.)

Social History: [Living situation and caregiver support; baseline mobility; tobacco/alcohol/drug use with last use when withdrawal/overdose possible; occupation if exposure risk relevant; driving status if seizures/syncope pertinent; pregnancy status when teratogenic risks relevant]

Review of Systems

[Targeted neurologic and systemic symptoms that materially affect the differential or workup] (Include only if it adds value beyond HPI; avoid comprehensive auto-negative blocks. Omit entire section if HPI already captures necessary symptoms.)

Physical Examination

Vitals and General: [Vital signs with notable trends; general appearance; airway/respiratory effort; perfusion; head/neck trauma signs; meningismus; cardiac rhythm/murmurs; lung exam; edema; skin findings]

Neurologic Examination: (Explicitly state exam limitations. Avoid "nonfocal" without supporting details. Ensure left/right consistency.)

• Mental Status: [Arousal; attention; orientation; language—fluency, comprehension, naming, repetition; memory; neglect; apraxia as relevant]
• Cranial Nerves: [Pupils; visual fields; extraocular movements; facial symmetry/sensation; hearing; palate/voice; tongue]
• Motor: [Bulk; tone; involuntary movements; pronator drift; strength with consistent grading and side specificity]
• Reflexes: [DTRs with grading; pathologic reflexes as relevant]
• Sensory: [Light touch; pinprick; temperature; vibration; proprioception; sensory level if myelopathy suspected]
• Coordination: [Finger-nose; heel-shin; rapid alternating movements]
• Gait: [Gait assessment] (If not tested, state why.)
• Bedside Severity Scale: [Stroke severity or syndrome-specific scale with score and time] (Include when applicable.)

Diagnostics Reviewed

• Neuroimaging: [CT/CTA/CTP/MRI findings with exact timestamps; comparison to prior studies] (State "ordered—pending" when not yet resulted.)
• EEG: [Routine/continuous EEG status; key findings if resulted] — [ordered—pending / running / resulted]
• Laboratories: [Key abnormalities or pertinent normals from CBC, CMP, glucose, coagulation, toxicology, infectious workup]
• Cardiac: [ECG interpretation; telemetry events; echocardiogram status/results]
• Outside Records: [Sources reviewed and key extracted information with verification status]

Assessment

Problem Representation: [Age/sex, key comorbidities, baseline function, presenting syndrome, acuity]

Localization: [Most likely neuroanatomic localization with brief justification tied to exam; if uncertain, list top 2–3 plausible localizations as hypotheses]

Differential Diagnosis:

• [Diagnosis 1] — [Supporting features]; [Opposing features]
• [Diagnosis 2] — [Supporting features]; [Opposing features]
• [Diagnosis 3] — [Supporting features]; [Opposing features]

(Include "can't miss" diagnoses—hemorrhage, CNS infection, nonconvulsive status, toxic ingestion—when clinically plausible. Ensure left/right consistency.)

Plan

1. [Problem 1: Working diagnosis or diagnostic question]

   • Immediate Safety: [Airway/breathing/circulation actions; neuro check frequency; BP targets; seizure/aspiration/fall precautions]
   • Diagnostics: [Tests ordered and diagnostic question each addresses]
   • Therapeutics: [Treatments/medications; reference protocols rather than detailed dosing]
   • Monitoring: [Telemetry/EEG; neuro check frequency; lab monitoring; escalation parameters]
   • Disposition: [Level of care; consults with specific clinical questions]
   • Contingencies: [If-then branches for time-sensitive pathways]

2. [Problem 2]

   • [Follow same structure as above]

Rehabilitation and Safety: [PT/OT/SLP consult triggers; swallow screen status and diet; DVT/VTE prophylaxis with contraindications; mobility plan]

Medication Reconciliation: [Home med holds/restarts with rationale]

Disposition Planning: [Anticipated course; criteria for ICU vs floor; expected discharge needs]

Condition-Specific Additions

(Include only the relevant module below.)

Acute Ischemic Stroke/TIA

• [Exact last known well/normal with source]
• [Stroke severity scale score with time]
• [Imaging timeline: CT, vascular imaging, perfusion with timestamps]
• [Reperfusion decision: thrombolytic given or withheld with explicit rationale; thrombectomy consideration]
• [Etiologic workup plan; swallow screen/NPO status; antithrombotic plan; statin indication; BP strategy; VTE prophylaxis]

Intracerebral Hemorrhage/Subarachnoid Hemorrhage

• [Onset time; headache features; trauma context]
• [Anticoagulant/antiplatelet exposure with last dose; reversal plan]
• [Neuro-ICU monitoring parameters; neurosurgery involvement; severity scoring]

Seizure/Status Epilepticus

• [Semiology: onset type, awareness, motor/non-motor features, duration, clustering, triggers]
• [Postictal state; injuries; epilepsy history; prior EEG/MRI; medication adherence]
• [Provoking factors; seizure precautions; EEG plan; rescue pathway per protocol]

Encephalopathy/Delirium

• [Time course; baseline cognition; fluctuation; medication/toxin review; withdrawal risks]
• [Exam signs: asterixis, meningismus as relevant]
• [Workup by category: toxic-metabolic, infectious, structural, seizure/NCSE, autoimmune]

Neuromuscular Weakness with Respiratory Risk

• [Weakness distribution; fatigability; bulbar/autonomic features]
• [Respiratory monitoring plan with bedside measures and ICU threshold; DVT risk; mobility plan]

Communication / Goals of Care

[Capacity assessment; surrogate decision maker; code status discussion; what was explained; family update plan] (Include only if addressed during encounter.)