UPHS - NEUROLOGY Date & Time: _____________________

INITIAL EVALUATION CONSULTATION

REQUESTED BY (NAME/SERVICE):______________________
CHIEF COMPLAINT:
NAME:
HISTORY OF PRESENT ILLNESS:
ROOM:

Patient Identifier

(>3: location, severity, timing, modifying factors, quality, duration, context, assoc si/sx)

Contact:
Neurological Review of Systems:

Primary:
Specialists:

PAST MEDICAL HISTORY:

FAMILY HISTORY:

SOCIAL HISTORY:
Tobacco:
Alcohol:
Drugs:

PMH/PFSH limited/deferred due to: Coma Altered MS Aphasia Intubation _______________________________

ALLERGIES:
MEDICATIONS:

REVIEW OF SYSTEMS:

(Complete all or check all other ROS negative below)

ROS deferred due to: Coma Altered MS Aphasia Intubation _____

Normal Abnormal (Elaborate)
Psych:
___
____________________
Const:
___
____________________
HEENT: ___
____________________
Skin:
___
____________________
Resp:
___
____________________
CV:
___
____________________
GI/GU:
___
____________________
Endo:
___
____________________
MSK:
___
____________________
Heme:
___

____________________

EXAMINATION

all other ROS negative

(Comprehensive exam: Must complete all * elements, with three or more vital signs and one cardiovascular element)

CONSTITUTIONAL
* Vital Signs:
(>3 from top row)

* Appearance

BP _____/_____ T _____ Tmax _____ HR _____ RR _____ Wt _____

O2/Ventilation _______________________________________Ht_____
Normal
___

Relevant Details (especially if abnormal)

__________________________________________________

* CARDIOVASCULAR (>1: carotids, auscultation, extremities)

Carotids
___
__________________________________________________
Heart
___
__________________________________________________
Peripheral vasc. ___
__________________________________________________
Other
Chest
___
__________________________________________________
Abdomen
___
__________________________________________________
MENTAL STATUS
MSE limited/deferred due to: Coma Aphasia Intubation __________________
* Attention
___
__________________________________________________
* Orientation
___
__________________________________________________
* Memory
___
__________________________________________________
* Language
___
__________________________________________________
Visuospatial
___
__________________________________________________
Executive
___
__________________________________________________
* Fund of knowledge ___
________________________________________________________
CRANIAL NERVES (complete all: Visual Fields and/or Visual Acuity, Fundi, CN 3-12; if CN 11 and 12 deferred, check boxes below)
* Visual Fields
___
__________________________________________________
Visual Acuity
___
__________________________________________________
* Fundi
___
__________________________________________________
* Pupils
___
__________________________________________________
Eye Movements ___
__________________________________________________
* V (Trigeminal) ___
__________________________________________________
* VII (Facial)
___
__________________________________________________
* VIII
___
__________________________________________________
* IX, X
___
__________________________________________________
* XI
___
__________________________________________________
* XII
___
__________________________________________________
CN 11-12 deferred due to: Coma Altered MS Aphasia Intubation ________

MOTOR
* Bulk, Tone
/ RUE
*- LUE
\ RLE
\LLE
Abnl Movement

___
___
___
___
___
___

__________________________________________________
_________________________________ Pronator Drift Yes No
_________________________________ Pronator Drift Yes No
__________________________________________________
__________________________________________________
__________________________________________________

* SENSORY (>1: LT, PP, temp, vib, prop, Romberg, noxious stimuli)
Light Touch
___
__________________________________________________
Pinprick
___
__________________________________________________
Temperature
___
__________________________________________________
Vibration
___
__________________________________________________
Proprioception ___
________________________________ Romberg Absent Present
* COORDINATION (>1: RAM, F-N-F, H-S)
Coordination deferred due to: Altered MS Aphasia _________
RAM
___
__________________________________________________
Finger - Nose
___
__________________________________________________
Heel - Shin
___
__________________________________________________
GAIT

Gait deferred due to: Bedrest Critical Illness/Intubation Altered MS _________

* Gait and Station ___

Tandem Walk
___
Toe/Heel Walk ___

__________________________________________________
__________________________________________________
__________________________________________________

* REFLEXES

OTHER (MMSE, Vestibular, Frontal Release signs, general exam etc.)

FF:

Toe:

:FF

:Toe

DATA
Neuroimaging: Personally reviewed

Other Radiology (CXR, TTE):

Neurophysiology (EEG, EMG):
CSF:

EKG:

Lipids:

U/A:

LFTs:

Ca:
Mg:
Ph:

ASSESSMENT AND PLAN

I have considered the patients home medications when writing admission orders

Resident Signature/Name: ______________________________________________________________

Pager Number: _______________________________

Date & Time: ______________________

ATTENDING NOTE
I have seen and examined this patient with/subsequent to the resident/fellow listed above. I agree with his/her history, review of
systems, family history, social history, physical examination, impression and plan as outlined in his/her note above with the
following additions/exceptions/observations, or
[ ] PLEASE SEE FULL ATTENDING NOTE IN CHART.
History remarkable for:

Physical Exam remarkable for:

Test results:
Assessment and Plan:

Attending Signature/Name: ______________________________

Date & Time: _________________

Pager Number: __________________