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WNA Neurological Consultation
The purpose of a neurological consultation is to allow the neurologist to gather information about the patient’s condition in order to diagnose the problem and plan a treatment.
Gathering Information
The process of collecting information begins when the patient arrives for the appointment. Each patient will be given several forms to fill out, one of which is a patient history. When the paperwork has been completed, a midlevel provider will call the patient from the waiting room and take him/her to an exam room. The midlevel provider will interview the patient concerning the following information:
- History of present illness: Location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms.
- Past medical history: Allergies, current medications, surgeries, injuries, other.
- Social history: Employment, marital status, children, habits.
- Family history: Parents, other.
- Review of systems: Constitutional (fever, weight loss, etc.), eyes, ENT, cardiovascular, musculoskeletal, respiratory, GI, GU, skin, endocrine, other.
The Examination
After the interview, an examination is performed and is divided into the following parts:
- Physical exam: Blood pressure sitting/standing, blood pressure lying, pulse, respirations, height, weight, general appearance, cardiovascular (carotids, heart, and peripheral).
- Mental status testing: Orientation times three, recent/remote memory, attention span/concentration, language, fund of knowledge.
- Neurological: A thorough exam including the 12 cranial nerves, muscle strength, tone, bulk, posture, gait, coordination, reflexes and full sensory exam.
Diagnosis and Treatment
After the history and examination, the midlevel provider will discuss all of the information and findings with the neurologist who will then see the patient and ask any further questions he feels might be helpful. He may also repeat parts of the examination. He will then discuss with the patient his opinions regarding diagnosis, further testing and treatment.
Testing/Procedures
Tests often used by neurologists to help assess a patient’s condition include CT, MRI, EEG, EMG/NCV, Lumbar Puncture and various types of blood testing.
Conditions Neurologists Diagnose
Neurologists diagnose and treat conditions such as strokes, transient ischemic attacks (TIA), dementia including Alzheimer’s disease, headaches, seizures (epilepsy), Parkinsonism, multiple sclerosis, amyotrophic lateral sclerosis (Lou Gehrig’s disease), herniated cervical and lumbar discs and other types of nerve entrapment.
Medical Records
All of the information collected during the neurological consultation, including the physical and neurological examinations and the doctor’s plan for treatment and/or testing will be dictated onto a tape. The tape will then be transcribed into a formal report of findings and placed in the patient’s chart for future reference.
Medical Records Release Form
