Pediatric Neurology Consultation Note (Inpatient)

Date/Time of Evaluation: [Date and time] (Use local time; if estimated, state so.)

Patient Location: [ED / floor unit / ICU; include hospital/campus if applicable]

Requesting Service: [Service and clinician name]

Reason for Consult: [One-line triage question as stated by requesting team]

Consultant: [Name and role]

Sources of History: [patient / parent-guardian / EMS / chart review / other] (Note limitations explicitly, e.g., patient intubated, parent unavailable; document attempts to obtain missing information.)

At-a-Glance Summary

(Include this section only when urgency is non-trivial; omit for clearly routine consultations.)

Triage Question: [Restated briefly]

Answer: [One-line response or what is needed to answer]

Urgency: [emergent / urgent / routine]

Neurologic Risk Statement: [Key safety concern succinctly stated]

Working Diagnoses: [Top 2–4 differential considerations, ranked]

Immediate Recommendations:

• [Action needed now or within 1 hour]
• [Additional immediate action] (Include 3–5 items as needed.)

Escalation Triggers: [Findings or changes that should prompt immediate re-contact]

History

Chief Concern: [1–2 lines describing the presenting problem] (Use patient/parent words when helpful.)

History of Present Illness:

[One-liner problem representation including age, relevant comorbidities, baseline neurodevelopment, and time course.] [Chronological narrative with clear time anchors including last known normal, onset, and progression.]

(Include problem-specific details as relevant to consult type: For seizure/spell—semiology, duration, postictal state, triggers, prior seizure history, current ASMs with adherence, rescue meds given with response. For headache/increased ICP concern—onset pattern, quality, associated symptoms, red flags. For encephalopathy/AMS—baseline deviation, tempo, exposures, systemic illness signs, subtle seizure features.)

Pertinent Past History:

• Neurologic: [Seizures, stroke, CP, headaches, shunt, neurocutaneous syndromes]
• Medical: [Conditions affecting neuro differential or medication choice]
• Birth/Development: [Perinatal history if relevant; developmental baseline and milestones]
• Family History: [Neurologic disease as relevant]
• Medications: [Current medications with last dose] (If unknown, document that information is being obtained.)
• Allergies: [Allergies with reaction type]

Examination

Vitals: [HR, BP, RR, Temp, SpO2, Weight] (Weight required for dosing; if unavailable, note that weight-based dosing is pending.)

General Exam: [Findings relevant to neurologic differential: meningismus, rash, trauma signs, dysmorphisms, neurocutaneous stigmata] (Include only pertinent positives/negatives.)

Neurologic Exam: (Age-adapt as appropriate. Do not document elements as normal if not assessed. If limited, explicitly state why and which elements could not be assessed.)

• Mental status/arousal/behavior: [Findings]
• Speech and language: [Findings or age-appropriate interaction]
• Cranial nerves: [Pupils, EOM, facial symmetry, palate, tongue; funduscopic exam if ICP concern] (Document if unable to perform.)
• Motor: [Tone, strength or antigravity movement, abnormal movements]
• Reflexes: [DTRs, plantar responses; primitive reflexes in infants when relevant]
• Sensation: [Findings as feasible for age and clinical state]
• Coordination: [Finger-nose, heel-shin, truncal stability as age permits]
• Gait and station: [Findings] (If deferred, state why.)
• Meningeal signs: [Findings] (Include when clinically relevant.)

Data Reviewed

(Include only data that influences current decision-making. Note whether imaging was personally reviewed vs. relying on radiology report.)

• Labs: [Glucose, electrolytes, CBC, inflammatory markers, toxicology, ASM levels with dates/times]
• Imaging: [CT/MRI head, vascular imaging; key findings, date/time]
• EEG/cEEG: [Type, time window, key findings including background and seizure burden]
• CSF: [Opening pressure, cell count/diff, protein, glucose, date/time] (Include if LP performed.)
• Microbiology: [Pertinent results relevant to neuro differential]

Assessment

Consult Question Answered: [Direct answer to the consult question. If uncertain, specify what remains unknown and what would resolve it.]

[Problem 1: Neurologic problem name]

[Brief summary of supporting evidence with key positives/negatives. Neuroanatomic localization if relevant. Focused, ranked differential prioritizing dangerous and treatable causes. Working diagnosis if reasonably established.] (Clearly distinguish facts from clinical inference.)

[Problem 2: Additional neurologic problem]

(Include additional problems only if present and discussed.)

Recommendations

Immediate (now or within 1 hour):

1. [Critical action with specific parameters]
2. [Critical action]

Urgent (within 6 hours):

1. [Time-sensitive workup or intervention] (Briefly state how result will change management.)
2. [Time-sensitive workup or intervention]

Ongoing:

• [Monitoring parameters and frequency; neuro check escalation triggers]
• [Nursing precautions: seizure precautions, aspiration precautions, positioning as indicated]

Contingency Plans:

• [If X occurs, then Y—include clear thresholds and actions]

(For medications: include drug name, weight-based dose in mg/kg, route, frequency, and monitoring. If dosing incomplete due to missing weight or renal function, state what is needed.)

Communication

[Closed-loop communication: who was contacted (name and role), method (phone / in-person / secure message), time, and key recommendations relayed.]

[Family/guardian communication if high-risk decisions were discussed.]

(If unable to reach primary team, document attempts and escalation pathway used.)

Follow-Up Plan

Neurology Follow-Up: [will follow daily / follow peripherally / sign off after initial recommendations]

Re-Consult Triggers: [Specific triggers: recurrent seizures, worsening exam, new focal deficit, abnormal EEG, or other defined changes]

Outpatient Follow-Up: [Clinic type and timeframe if actionable] (Omit if not applicable.)

(Omit sections not relevant to this consult. If information is missing but materially affects safety or decision-making, state that it is unknown and will be updated when available.)