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Consult / H&P Template

Last modified by Hussein Abdallah on 2025/04/20 20:09

Standard Consult/H&P

Universal TemplateExample

Neurosurgery Attending: 
Dx: 
IC: 
CC: 

HPI: 

Denies HA, vision changes, speech changes, nausea/vomiting, weakness, numbness/tingling, signs/sx of seizure, bowel/bladder incontinence, saddle anesthesia. 

PMHx: 
PSHx: 
Social Hx: 
Meds: 
Allergies: 

NEURO EXAM

IMG: 

ASSESSMENT/PLAN: 

Staffed with Chief 
Staffed with Attending

Provider Name & Title
Pager #

Neurosurgery Attending: Paul A Gardner
Dx: 2.5cm pituitary adenoma 
CC: H1 tunnel vision 

HPI: 67F on Xarelto (Afib, last dose 4/20) who p/w  

PMHx: Afib, HTN, HLD 
PSHx: no brain/spine surgery
Social Hx: retired teacher, 
Meds: +Xarelto, no other aspirin, plavix, warfarin, eliquis, brilinta
Allergies: none 

NEURO EXAM
EOS 
Ox3
PERRL, EOMI, FS, TML 
VA: 20/20 | 20/30 
VF: bitemporal hemianiopsia 
​55555/55555
55555/55555
SILT 

IMG: PUH 
MRI Pituitary w/wo heterogenously enhancing mass R >L cavernous invasion (Knosp 1)  

ASSESSMENT/PLAN: 
- Admit to NSGY, floor 
- Pituitary labs
- ENT c/s
- Optho c/s 
- OR plan to follow

Staffed with Chief Ali A Alattar MD 
Staffed with Attending Paul A Gardner

Hussein M. Abdallah MD 
NSGY Resident, PGY2
Pager x87406 

Pediatrics

Neurosurgery Attending: 
Dx: 
CC:
INJURY COMPLEX: 

HPI: obtained w/ assistance of  at bedside
no AP/AC w/ unremarkable PMHx 

PMHx: Denies
PSHx: No brain or spine surgery. 
SOCIAL Hx: 
FAMILY Hx:  non-contributory
BIRTH Hx:  non-contributory
ANTIPLATELET/ANTICOAGULATION: Denies current use. 
MEDICATIONS: Denies chronic medication use 
ALLERGIES: Denies known allergens, NKDA

REVIEW OF SYSTEMS: 
Constitutional: No sleep disturbance, weight gain or loss.
Skin: No rashes or sores.
Eyes:  No strabismus. 
ENT: No ear infections or hearing loss. 
Respiratory: No wheezing or shortness of breath. 
Cardiac: No chest pain. 
GI: No vomiting, diarrhea, or constipation. 
GU: No urinary incontinence or urinary tract infections. 
Musculoskeletal: No joint swelling or pain. 
Neurological: No seizures. 
Hematologic/Lymphatic: No frequent or easy bruising

GENERAL EXAM: 
Skin:  Warm.  dry.  intact.   
Head:  Normocephalic.  atraumatic.   
Neck:  Supple.  trachea midline.  no tenderness.  no lymphadenopathy.   
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  no jaundice.   
Ears, nose, mouth and throat:  Oral mucosa moist.  No pharyngeal erythema or exudate.    
Respiratory:  Respirations are non-labored.  
Gastrointestinal:  Soft.  Nontender.  Non distended.  
Musculoskeletal:  Moves all extremities  
Lymphatics:  No lymphadenopathy 
Psychiatric:  Cooperative

NEURO EXAM: 
 

IMAGING: server: CHP

A/P: 
-  
- 

Plans communicated to Dr. _ of _
Staffed with fellow Dr. Martin Piazza and attending 

Hussein Abdallah MD
NSGY Resident PGY-1    
Pager 4126 

Add-ons (dot-phrases)

Oncology

ONCOLOGY HISTORY

+ Dx: 
+ Prior systemic tx: 
+ Current systemic tx: 
+ Known neuro-axial mets and tx:
+ Primary oncologist and last pertinent f/u: 

Bulbar Symptoms

Pituitary Review of Systems

Corticotroph: denies GI sx (abdominal pain, n/v), weight gain, increasing waist circumference, proximal muscle weakness, easy bruising, skin changes, recurrent infections, easy fractures

Gonadoptroph: endorses normal libido, has morning erections

Thyrotroph: Denies heat/cold intolerance, denies fatigue, constipation / diarrhea

Somatotroph: Denies change in shoe size/ring size, snoring, facial changes 

Lactotroph: Denies galactorrhea  

Posterior pituitary: Denies polyuria and nocturia, excessive thirst

mJOA