Neurology Inpatient Consultation Note

Consult Information

• Note Type: Neurology Inpatient Consultation Note
• Date/Time: [Date and time of evaluation]
• Requesting Service: [Requesting team/clinician name]
• Consult Question: [Specific consult question in requesting team's words]
• Urgency: [routine / urgent / emergent] [Deadline if specified]
• Patient: [Name], [Age], [MRN], [Location]

Data Sources and Reliability

[History sources] (Specify sources: patient, family, chart, EMS, bedside nurse.) [Reliability assessment: reliable / limited due to aphasia, encephalopathy, intubation, sedation, language barrier] [Exam limitations and reasons if applicable] (If key history unobtainable, state why.)

Clinical Summary

Restated Consult Question: [Brief restatement of the question]

[One-sentence patient summary: age, key comorbidities, current setting, neurologic syndrome, time course]

History of Present Illness

[Narrative HPI] (Begin with the consult question and timeline. Include onset and course [acute/subacute/chronic; progressive/fluctuating], last known well for acute deficits, associated neurologic symptoms, relevant pre-hospital and in-hospital events, and baseline neurologic function. Include discriminating pertinent negatives only. Do not infer information not explicitly obtained.)

• Stroke/TIA details: [LKW/time first known abnormal], [vascular risk factors], [antithrombotic status and last dose], [bleeding risk factors] (Include if relevant.)
• Seizure details: [Semiology], [duration], [postictal state], [ASM history], [recent levels] (Include if relevant.)
• Encephalopathy details: [Baseline cognition], [tempo], [sedation/analgesia timeline and doses] (Include if relevant.)
• Headache details: [Onset and quality], [red flags], [positional features], [triggers], [associated focal symptoms] (Include if relevant.)
• Weakness pattern: [Distribution], [fatigability], [sensory involvement], [bulbar/respiratory symptoms] (Include if relevant.)

Relevant Background

• Neurologic history: [Prior stroke/TIA, epilepsy, dementia, neuropathy, movement disorder, demyelinating disease, neuromuscular disease] (Only include items affecting localization, differential, testing, or treatment.)
• Other relevant comorbidities: [Atrial fibrillation, cancer, immunosuppression, coagulopathy, pregnancy/postpartum, infection risk]
• Relevant medications: [Antithrombotics with last dose timing], [antiseizure medications], [sedatives/analgesics/anticholinergics], [agents affecting mental status or coagulation]
• Allergies: [Allergies relevant to recommended medications or contrast] (Omit if none relevant.)

Review of Systems

[Focused ROS with discriminating positives/negatives not in HPI] (Include only if adding information relevant to localization or etiology. If unobtainable, state why. Omit section entirely if redundant with HPI.)

Physical Examination

• Vitals: [Temperature], [blood pressure], [heart rate], [oxygen saturation], [serum glucose] (Include values relevant to neurologic assessment.)
• General: [Cardiac rhythm], [signs of infection], [respiratory status], [other pertinent findings] (Include if relevant to embolic risk, infection, or respiratory status.)

Neurologic Examination (Document systematically with laterality and distribution. State reason for any element not assessed. Do not document normal findings for elements not examined.)

• Mental status: [Arousal], [orientation], [attention], [language], [memory], [neglect]
• Cranial nerves: [Pupils], [EOMs], [visual fields], [facial symmetry and sensation], [palate], [tongue], [dysarthria]
• Motor: [Bulk], [tone], [pronator drift], [strength by muscle group with laterality], [abnormal movements]
• Reflexes: [DTRs with grades and symmetry], [plantar responses]
• Sensory: [Light touch], [pinprick], [vibration/proprioception], [distribution and asymmetry]
• Coordination: [Finger-to-nose], [heel-to-shin], [rapid alternating movements]
• Gait/station: [Gait pattern], [postural stability], [assistive devices] (Include if safe to assess; state reason if deferred.)
• NIHSS: [Total score and sub-scores] (Include for suspected stroke.)
• GCS: [Eye/Verbal/Motor components and total] (Include for coma or ICU patients.)
• Meningeal signs: [Nuchal rigidity/Kernig/Brudzinski] (Include if meningitis or SAH suspected.)
• Exam limitations: [Limitations and reasons: intubation, sedation, agitation, safety concerns] (Include if applicable.)

Data Review

(Curate pertinent data only. Distinguish independent interpretation from report review. Avoid raw data dumps.)

• Laboratory data: [Key abnormalities or rule-in/rule-out labs with dates and clinical relevance]
• Neuroimaging: [Study and date] – [Key findings]. (State if personally reviewed: "On my review..." vs "Per radiology report...")
• Neurodiagnostics: [EEG/cEEG findings], [EMG/NCS], [LP results with opening pressure] (Include dates.)
• Other studies: [Cardiac studies, vascular imaging, infectious work-up] (Include if relevant.)
• Interprofessional communication: [Key discussions with other teams affecting management]
• Pending studies: [Studies pending], [who will follow results], [expected timeframe]

Impression

[Narrative impression: neurologic syndrome, neuroanatomic localization with neuroaxis level and lateralization, time course characterization, leading etiology with justification, immediate threat assessment]

Answer to Consult Question: [Direct, concise answer to the requesting team's question]

Problem-Oriented Assessment

(List problems in order of urgency.)

• [Problem 1]: [Working diagnosis]

  • Localization: [Anatomic localization with laterality]
  • Differential: [Prioritized list with supporting/refuting features]
  • Key uncertainties: [Information gaps or diagnostic ambiguities]
  • Risk if missed: [Consequences of delay or misdiagnosis]

• [Problem 2]: [Working diagnosis]

  • Localization: [Anatomic localization]
  • Differential: [Prioritized list with supporting/refuting features]
  • Key uncertainties: [Information gaps]
  • Risk if missed: [Consequences]

  (Include additional problems as needed.)

Recommendations

(Numbered, specific, actionable. For each: what to do, when, who is responsible, what to monitor, when to escalate.)

Diagnostics

1. [Imaging with specifications: modality, contrast, vascular/spine level, timing, responsible service]
2. [EEG type, duration, and clinical goal]
3. [LP with studies to send, anticoagulation guidance, and timing]
4. [Targeted labs with rationale]

Therapeutics

1. [Medication name, dose, route, frequency, titration parameters, monitoring]
2. [Antithrombotic management plan]
3. [Antiseizure medication management]
4. [Other condition-specific treatments]

Monitoring and Nursing Care

1. [Neuro check frequency and criteria for escalation]
2. [Vital sign targets: BP, HR, temperature, glucose goals]
3. [Precautions: aspiration / fall / seizure]
4. [Therapy consults: PT / OT / SLP / swallow evaluation]

Contingency Plans

• If [new focal deficit or mental status decline], then [STAT CT head, check glucose, page neurology]
• If [clinical or EEG seizures], then [loading dose and maintenance plan, notify neurology]
• If [respiratory weakness: NIF decline or bulbar symptoms], then [monitoring frequency, ICU escalation criteria]

Communication and Disposition

• Primary team communication: [Discussed with team/clinician name, summary of discussion]
• Neurology follow-up: [Neurology will follow daily / follow peripherally / sign off]
• Re-consult criteria: [Specific indications to re-consult neurology] (Include if signing off.)
• Outpatient follow-up: [Neurology clinic follow-up needs] (Include if applicable.)

Patient and Family Discussion

[Summary: what was explained, risks/benefits discussed, patient/family understanding and preferences, decisions made] (Omit section if no significant discussion occurred.)