Neurosurgery Inpatient Consultation Note

Date/Time of Consult: [Date and time]

Location: [ED / floor / ICU and unit]

Patient Name: [Full name]

MRN: [Medical record number]

DOB: [Date of birth]

Consulting Service: Neurosurgery

Author/Role: [Name, credentials, and role]

Source of History: [patient / family / EMS / chart review / other] (Note interpreter use if applicable.)

Consult Request

• Requesting service/clinician: [Service and clinician name/role]
• Reason for consult: [Specific neurosurgical question]
• Urgency: [routine / urgent / emergent]
• Scope requested: [recommendations only / co-management / procedure evaluation]
• Clarification obtained: [Final agreed question] (Only include if the initial consult question was unclear.)

Summary

[One-paragraph synthesis including patient descriptor with key comorbidity and reason for consult, current neurologic status vs baseline with GCS if relevant, key imaging finding with modality and date/time, immediate risk statement if threat to life or neurologic function, and current supports such as intubation, sedation, vasopressors, or anticoagulation] (If exam reliability is limited, state why.)

History of Present Illness

[Consult context and timeline beginning with why neurosurgery is involved; onset and progression; last known normal for neurologic change when applicable; mechanism; symptoms and neurologic trajectory including headache, vomiting, seizure, weakness, sensory changes, language or vision changes, bowel/bladder dysfunction; interventions already performed; pertinent negatives narrowing life-threatening etiologies] (If history cannot be obtained from the patient, document why and list alternative sources used.)

Pertinent History

• Prior neurosurgical/neurologic conditions: [tumor / aneurysm / AVM / shunt / Chiari / spine surgery or instrumentation / craniotomy / other]
• Cancer history: [Primary site and metastatic potential, or none]
• Immunosuppression/dialysis: [Status and relevant details]
• Anticoagulants/antiplatelets: [Agent(s) and last dose time] (If unknown, document uncertainty and verification plan.)
• Other relevant medications: [Steroids with dose/duration, antiseizure medications, opioids/sedatives affecting exam]
• Allergies: [Drug/contrast/latex and reaction type]
• Baseline function: [Ambulation, ADLs, cognition]
• Goals of care: [Code status and decision-maker/surrogate if relevant to operative candidacy]

Physical Examination

Vital signs: [SBP range, HR, RR, SpO2 with O2 requirement, temperature]

General: [Trauma signs, scalp lacerations/hematomas, CSF leak signs, meningismus, spine tenderness/deformity] (Include only relevant findings.)

Neurologic Examination

Mental status: [Alertness, orientation, attention, aphasia/dysarthria] (Note if limited by sedation, paralysis, intubation, or delirium.)

GCS: [E_ V_ M_ = Total] (Include caveat if sedated, paralyzed, or intubated.)

Pupils: [Right size/reactivity; Left size/reactivity]

Cranial nerves: [Extraocular movements, facial symmetry, gag/cough]

Motor: [Strength by muscle groups or limbs with asymmetry and drift noted]

Sensation: [Grossly intact or dermatomal pattern if spine concern]

Reflexes: [DTRs; Hoffman, Babinski, clonus when relevant]

Coordination/gait: [Findings, or state why not assessed]

Spine/SCI Examination (Include when spinal cord injury or cauda equina syndrome is suspected.)

• Motor and sensory levels: [Levels by side]
• Sacral sparing: [Perianal sensation, toe flexion, anal wink]
• Perineal sensation: [intact / impaired / absent]
• Rectal tone: [normal / reduced / absent]
• Voluntary anal contraction: [present / absent]
• Bladder function: [Retention/incontinence status; post-void residual if available]

(If any element is not performed, explicitly state why rather than omitting.)

Wounds/devices: [Shunt sites, EVD/bolt sites, post-op incisions, spine hardware, drains with appearance and function] (Include when applicable.)

Data Reviewed

Imaging

• [Modality and region] [Date/Time]: [Key finding and clinical impact] [images reviewed personally / radiology report reviewed] (Note comparison studies with stability or progression when available.)

Labs

[Decision-driving values with timestamps: CBC with WBC and platelets, BMP with Na and Cr, coagulation studies with INR and PTT, type and screen status, lactate or inflammatory markers if relevant to infection concern]

Other Relevant Data

• ICP/EVD: [ICP range and trends; EVD settings and output]
• EEG: [Findings]
• Hemodynamics: [Vasopressor agents and doses; targets]
• Ventilator: [Mode, FiO2, PEEP; sedation/paralysis affecting exam or operative risk]
• External records: [Salient points from outside hospital records]

(Include only elements that are present and relevant to the consult.)

Assessment

[1–3 sentence summary stating the working diagnosis or top differential, current severity and why it matters now, supported by exam, imaging, and trajectory]

[Problem 1: Primary neurosurgical diagnosis]

[Status and severity; key supporting evidence from imaging and exam; differential diagnosis if meaningful uncertainty exists]

[Problem 2: Secondary concern]

[Status and supporting evidence] (Include additional problems in descending acuity as relevant.)

Recommendations

• Monitoring: [Neuro checks frequency; pupillometry]
• Physiologic targets: [SBP/MAP, sodium/osmolar goals, PaCO2, temperature]
• Repeat imaging: [Modality, timing, and triggers for earlier imaging]
• Anticoagulation management: [Hold/reversal plan; target INR/platelets/fibrinogen]
• DVT prophylaxis: [mechanical / chemical with timing tied to bleed stability]
• NPO status: [NPO if surgery possible; swallow evaluation if indicated]
• Medications: [Analgesia, antiepileptics, steroids, hyperosmolar therapy with targets]
• Positioning/activity: [Head-of-bed angle, spine precautions, activity limits]
• Additional consults: [Anesthesia, critical care, neurology, hematology, etc.]
• Contingencies: [If X, then Y with explicit thresholds] (Example: If GCS drops ≥2 points, obtain STAT CT head and page neurosurgery immediately.)

Operative Plan

• Operative candidacy: [candidate / not a candidate] [Rationale if not a candidate]
• Proposed procedure: [Procedure name] – [emergent / urgent / elective during admission]
• Prerequisites: [NPO duration, type and screen, blood availability, platelet/INR goals, medical optimization]
• Post-operative plan: [Anticipated location, monitoring level, drains/EVD management]
• Consent: [obtained / pending] [Decision-maker if patient lacks capacity]

(If surgery is deferred, document rationale and criteria for reconsideration.)

Non-Operative Plan

• Management focus: [What to monitor and what to avoid with specifics]
• Re-imaging: [Timing and indications]
• Neurosurgery follow-up: [daily rounding / PRN / sign-off with return precautions]
• Outpatient needs: [Clinic follow-up timeframe and additional testing]

(Include either Operative Plan or Non-Operative Plan based on recommendations; include both if surgery is conditionally planned.)

Communication

• Primary team notified: [Name and role]
• Method and time: [phone / page / in-person] at [time]
• Recommendations communicated: [Brief summary of key points discussed]