Neuro and Movement Disorders

RE: [insert patient full name] Dear Dr [insert name of referring doctor] Thanks for referring this patient for the review. Accompanied by [name of accompanying person] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Referred by [name of referring doctor] Although her/his history is well known to you, I will reiterate it for my records. - [Insert reason(s) for consultation, including specific neurological concerns or symptoms such as headache, seizures, weakness, numbness, tingling, movement disorders, memory loss, etc.] (Only include reasons for consultation or neurological concerns if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Detailed history of the presenting complaint(s), including tempo of onset, duration, progression, last time patients was feeling normal, severity, pattern of symptoms, aggravating/alleviating factors, associated neurological or systemic symptoms, any previous treatments and responses.] (Only include detailed history of presenting complaints if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Detailed history of motor fluctuations during the day, including first hour in the morning, change in symptoms after first medication, degree of improvement, medication lasting effect in hours, presence or absence of dyskinesia, tremor, freezing of gait, shuffling gait, falls and frequency, presence of side effects of medications, symptom severity during the day, symptoms severity before going to sleep, nocturnal symptoms.] (Only include detailed history of presenting complaints if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Detailed history of non-motor symptoms, sleep problems, memory or cognitive issues, urinary symptoms, constipation, bowel habits, hallucinations, delusions, psychosis, impulse control disorders, pain, neuropathy signs.] (Only include detailed history of presenting complaints if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Medical history - [Past medical and surgical history, highlighting any previous neurological diagnoses, brain or spinal surgeries, hospitalizations, outcomes, etc.] (Only include past medical and surgical history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Allergies, including allergies to medications (especially those affecting the nervous system), etc.] (Only include allergies if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Social history, focusing on lifestyle factors, occupation, smoking, alcohol use, recreational drug use, family history of neurological diseases, etc.] (Only include social history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Quality of life, factors affecting quality of life, expectations with medical treatment] (Only include allergies if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Medications - [Current medications, time of intake, including any neuro-specific medications, over-the-counter medications, supplements, etc.] (Only include current medications if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Clinical examination - [Vitals] (Only include [vital signs] if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Clinical examination findings, including general examination and focused neurological examination assessing mental status, Luria sequence, agnosia, apraxia, cranial nerves, oculomotor examination, motor system (strength, tone), sensory system, reflexes, coordination, gait, etc.] (Only include physical examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Investigations - [Investigations with results, including laboratory tests, imaging tests, Brain MRI electrodiagnostic tests (e.g., EEG, EMG), etc.] (Only include investigation results if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Diagnostic impression [1. Neurological Issue, syndrome or Condition] - [Assessment, including the likely diagnosis and rationale based on subjective and objective findings with a focus on neurology.] (Only include assessment and rationale if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own assessment or diagnosis.) - [Differential diagnosis.] (Only include differential diagnosis if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own differential diagnosis.) Diagnostic plan - [Investigations planned, including any imaging, electrodiagnostic testing, lumbar puncture, etc.] (Only include investigations planned if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Treatment and Management plan - [Medical treatment planned, including details such as medication, dosage, expected outcomes, potential side effects, etc.] (Only include medical treatment plan if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own medical treatment plan.) - [Lifestyle modifications, including sleep hygiene, stress management, dietary advice, etc.] (Only include lifestyle modifications if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never suggest your own lifestyle modifications.) - [Mention any referrals to specialties or services.] (Only include referrals if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans.] (Only include follow-up appointments if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own assessment or plan, always use the transcript and contextual notes for this.) [2. Additional Neurological Issues or Conditions] - [Follow the same structure as above for each additional issue or condition identified.] (Only include additional neurological issues or conditions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own assessment or plan, always use the transcript and contextual notes for this.) [Additional Notes:] - [Patient education on the diagnosed condition, including explanation of the neurological disorder, its impact on daily life, potential complications, and the importance of treatment adherence.] (Only include patient education if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Instructions for monitoring and managing symptoms, including when to seek urgent care for symptoms such as sudden worsening of condition, new seizures, or signs of stroke.] (Only include symptom management instructions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Any specific patient or family concerns addressed during the consultation.] (Only include specific patient or family concerns if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Write in a detailed narrative, eloquent way and include all the information in structured paragraphs. Do not leave out any information written in the note. No bullet points or acronyms. Include everything that has been written in the history, past medical history, medications, allergies, social history, family history, physical examination, investigations, diagnostic impression and management plan into a structured paragraph. Do not summarise the physical examination.)