Neurology Consultation Transcribed Medical Transcription Sample Report


DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Consultation requested for headache.

CHIEF COMPLAINT:  The patient is a (XX)-year-old right-handed female complaining of headache.

HISTORY OF PRESENT ILLNESS:  The patient notes that she has had migraine headaches since she was (XX) years old.  Her migraines tend to have consistent features; in addition, sometimes have variable symptoms.  For example, the patient notes that when she was a teenager and early on her migraine history, she would have left facial droop and paresthesias of the left upper extremity prior to her headaches.  More recently, the pattern has changed, to be described further on below.  The patient notes that her usual migraine frequency is once or twice a month, for the most part, along with her menses, although they can occur independent of her menses less often.  That has been her pattern for the past 1-1/2 years, but prior to that, she was only having one or two migraines per year.  In November, her gynecologist began to try hormonal manipulation to see if the migraines could be better controlled.  The patient started by using a NuvaRing and if anything this seemed to increase the frequency of her migraines, as she has had a migraine headache on the average of once a week since this was instituted. The patient had another migraine on Monday and called her gynecologist and decided to go off the NuvaRing at that time.  Instead, the gynecologist started Camila 0.35 mg daily, which she took for three days prior to admission.  She notes that her menses had been very irregular and in fact that she has been having some amount of vaginal bleeding for the past 1-1/2 months as well.  She is uncertain as to whether the additional hormones she has gotten has changed that pattern.  Typically, the patient does not take any treatment for her migraine; although, she has found that sleep will take away the major portion of the pain, and that is how she has been treating these.  She tries Tylenol Extra Strength, but it does not give relief.  Her migraine typically begins with visual disturbances.  She will either have scotomata in her peripheral visual fields or scintillating scotomata in the same regions.  Yesterday at 10 o'clock, she had the sudden onset of scotomata, which lasted for 15 minutes and then these became scintillating for another 15 minutes.

Next, the patient developed her typical weakness of the left upper extremity, which has been an associated feature with her migraines for many years now.  This is more of a heaviness without true weakness.  Almost simultaneously, she developed paresthesias of her right upper extremity, which is a symptom that she has never had.  These symptoms lasted for 15 to 20 minutes.  In addition, the patient had some amount of slurred speech during these events.  Subsequently, the patient developed atypical headache, which usually involves the right cranium much more so than left.  This is usually behind the eye on the right and, yesterday, also involved the vertex and then spread in atypical fashion to right capital occipital artery regions.  The quality of the headache is that of a throbbing and pulsating sensation.  There is anorexia and nausea associated with it, with occasional vomiting.  The headache typically worsens with coughing, sneezing, straining for a bowel movement, or otherwise engaging in Valsalva maneuver. The patient denies focal weakness of a significant nature, other numbness, tingling, or dysesthetic sensations of the face or lower extremities.  No other visual complaints.  The patient has chronic tinnitus in the left ear.  She complains of an orthostatic sense of lightheadedness and presyncopal sensations without vertigo, which occurs when arising rapidly from the supine or seated position.  The symptoms are not precipitated by rapid movements of the head upon neck or by bending over.  Sometimes she feels these symptoms even when she is just sitting and doing nothing.  No other bulbar symptoms.  No history of recent or remote head, neck or low back trauma, with or without loss of consciousness.  Denies previous CNS infections.  No bowel, bladder or sexual dysfunction.

PAST MEDICAL HISTORY:  Known mitral valve prolapse.  The patient denies diabetes, hypertension, myocardial infarction, cardiac arrhythmia, anginal pectoris, current chest pain or pressure, kidney or liver disease, previous stroke, epilepsy or other neurologic or psychiatric illness.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  She denies abuse of tobacco, alcohol, prescription drugs or illicit substances.

ALLERGIES:  No known food, drug or contrast material allergies.

MEDICATIONS:  See HPI.  Vicodin as necessary for lingering headache pain.

REVIEW OF SYSTEMS:  Please see the HPI for neurologic and other pertinent review of systems, otherwise the following systems are noncontributory including constitutional, eyes, ears, nose, and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin and/or breast, endocrine, hematologic/lymph, allergic/immunologic and psychiatric.

PHYSICAL EXAMINATION:
GENERAL:  The patient is pleasant, cooperative, appears her stated age.  Her body habitus is endomorphic and she is mildly overweight.
VITAL SIGNS:  Currently stable.  The patient is afebrile.
SKIN AND EXTREMITIES:  No skin rashes or lesions are noted.  No cyanosis, clubbing or edema of the extremities.
HEAD AND NECK:  Head is normocephalic and atraumatic.  The head and neck are nontender without thyromegaly or adenopathy.  Carotid upstrokes are 1+/4.  No cranial or cervical bruits.  The neck is supple with a full range of motion.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation.
ABDOMEN:  Soft and nontender.
BACK:  Back is straight without midline defect.
NEUROMUSCULAR:  Higher cortical function/mental status:  The patient is alert.  She is oriented x3 to time, place and person.  There is no gross evidence of aphasia, apraxia or agnosia.  Recent and the remote memory appear normal.  The patient has a good fund of knowledge.
  Cranial nerves:  Pupils are 4 mm, reacting briskly to 2 mm without afferent pupillary defect.  Visual fields are intact to confrontation testing.  Funduscopic examination reveals sharp disk margins with normal vasculature.  No papilledema, hemorrhages or exudates.  Extraocular movements are full and smooth with normal pursuits and saccades.  No nystagmus  noted.  The face is symmetric.  The remainder of the cranial nerves are intact and symmetrical.  Strength is 5/5 throughout with normal tone and bulk with the following exceptions, 4/5 intrinsic muscles of the hands and feet.  No involuntary movements noted.  Reflexes are 2/4 and symmetrical in the upper extremities, 2/4 and symmetrical at the knees and 1/4 and symmetrical at the Achilles tendon.  Plantar responses were downgoing bilaterally.  Sensation:  Intact to pinprick, light touch, vibration and proprioception.  Coordination:  The patient normally performs finger-nose-to-finger, heel-to-knee-to-shin and rapid alternating movements in a symmetrical fashion.  Gait and station:  The patient walks with a narrow-based gait.  She is able to heel-toe and tandem walk forward and backwards without difficulty.  Romberg and monopedal Romberg are negative.

LABORATORY STUDIES:  On admission, CBC is normal.  Electrolytes are normal other than CO2 of 22.  Normal SMAC and magnesium.

DIAGNOSTIC STUDIES:  CT scan of the brain without contrast infusion is normal.  Results of the MRI of the brain and MR angiogram are pending.

IMPRESSION:  It appears that the patient suffers from migraine headaches with aura and other variable complicated symptomatology, which in the past has been primarily catamenial in its nature.  However, more recently, the patient has had an increase in the frequency of her migraines, possibly related to trials of estrogen and progesterone that have been initiated by her gynecologist versus the possibility that she is entering into hormonal fluctuations related to menopause as an alternative explanation.

RECOMMENDATIONS:  The patient has recently decided to discontinue her hormone replacement therapies and I agree with this approach.  With some time, it might be possible to see as to whether the migraines were increasing in frequency as a result of these treatments, or whether they will continue to be this frequent, in which case it may be related to the earliest phases of menopause.  I agree with the current narcotic analgesic treatment that the patient is receiving for her lingering migraine headaches.  The results of the MRI scanning of the brain, as well as MR angiography are currently pending.  As an outpatient, the patient should be on a migraine prophylaxis with either beta blockers, tricyclic antidepressant medications or anticonvulsants like Depakote.  These would be treatments that would be best applied on an outpatient basis.  The patient is asked when she leaves the hospital to begin taking an Ecotrin tablet 325 daily with her breakfast.  At times, even the simple use of the daily aspirin therapy will provide adequate prophylaxis against migraine headaches.

For symptomatic relief, she is asked to take Excedrin Extra Strength and she will take 2 tablets every 3 to 4 hours for her more severe migraines.  If that should fail and the migraine continues to progress, then as an outpatient, the patient should resume the use of Midrin, which she has used successfully in the past, taking 1 or 2 capsules of the brand medication (as the generic clearly does not work as well) - up to a maximum of 6 in any one day.  Her use of sleep as rescue therapy is also entirely appropriate if nothing else works. The patient agrees to follow up with me in the office after discharge.

Neuro Consult MT Sample Report 

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REASON FOR CONSULTATION:  Subdural hematoma, assault.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic male, legally blind since birth, admitted after an assault.  During this, he suffered extensive subarachnoid hemorrhage, LeFort fracture of the face, right arm venous phlebitis, and subdural hematoma.  He was maintained on SICU, prophylaxis Dilantin, because of extensive subarachnoid hemorrhage.  He went to the OR for facial ORIF.  His course was complicated by ventricular tachycardia, but he was ruled out for MI at that time.  He was started on amiodarone for the rate control.  He also suffered a mandibular fracture so PEG was placed because of his inability to eat.  No mention is made of acute seizure in this patient.  There is no report of CTs anywhere in the papers, which came with him.  Preadmission summary states intracerebral hemorrhage and subdural hematoma, although they do not state where.  He had to be emergently intubated due to hypoxemia. Other complications, during his hospital course, include cellulitis around the trach site, FUOs, and sinusitis.  He has phlebitis in his right forearm.  Repeat head CT showed increased bilateral frontal subdural hygroma and subarachnoid hemorrhage.  He also developed hyphema of the right eye.  He went to the OR for excision of a septic thrombophlebitis vein and I&D of the forearm on the right.

PAST MEDICAL HISTORY:  Hypertension.

FAMILY HISTORY:  Hypertension and stroke.

SOCIAL HISTORY:  He smokes a pack a day and occasional alcohol.  Otherwise, independent prior to the admission.

MEDICATIONS:  Prednisone, bacitracin topical cream, amiodarone, vancomycin, methadone b.i.d., dalteparin subcu daily, BuSpar 10 mg b.i.d., metoprolol 50 mg b.i.d., Pepcid, and Percocet.

PHYSICAL EXAMINATION:  The patient is alert.  He is oriented x3.  Simple attention is intact.  Sustained attention is fairly good with word list generation of 20 fruits and vegetables in one minute.  His language is fluent, but his long-term memory is poor for political events and historical events.  He is unable to tell me who ran against the present president, unable to state prior presidents.  Short-term recall is 2/4 word pairs at one minute, 3-1/2 with cues.  After a 5-minute delay, he recalled 2 spontaneously and 3 with cues.  Insight into his condition was moderately impaired, and visuospatial was not tested.

The patient has nystagmoid movements.  Pupils are irregular and not reactive but equal grossly in size.  Fundi were poorly visualized because of nystagmoid movement.  Face is symmetric.  Blink to threat was not available because of the decreased visual acuity.  He did not open his jaw for palate examination because of his fracture.  He has an incision line with staples in the throat, under chin area, wide open sutures healing by secondary intention in both forearms.

Motor exam shows at least 3+ to 4 strength in both upper and lower extremities with no focal weakness.  Reflexes are 2+ in the knees, biceps, and triceps, one in the ankles.  His toes go down.  He has dysesthesia in the feet to sensory stimulation, with decreased to pinprick distal and proximal fashion.  No extinction with double simultaneous stimulation.  No ataxia.  Gait was not examined.

IMPRESSION:  The patient is apparently status post bifrontal subdural hygroma after an assault.  He is now three weeks out from this injury, but its nature and its extent are unclear to us.  There is not enough information in chart or in the records that were sent with the patient to evaluate the extent of his neurologic injury.  His Glasgow coma scale on admission was reportedly 13, by secondary source materials, so one would expect that he had a mild brain injury with a Glasgow coma scale that high.  Currently, he presents with impairment and sustained attention, long-term memory, new learning, insight, but did not appear to be impulsive and did not appear to be particularly abulic either.

RECOMMENDATIONS:
1.  Instill sleep and manage his pain.
2.  We will review his head CT.
3.  His prognosis apparently is good given the fact that he has day-to-day information and recall and mild impairment at least in a relative way on his Glasgow coma scale on admission.  We do not expect a return to the community.  He may return to the community independently in the next three to six months in terms of decision-making and assistance at home.  We will continue to follow him.


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DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Left arm weakness.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed man. We were asked to see him for a progressive left hand severe weakness over the last year and also some mild right hand weakness, progressing over the last few months. He does not complain of any neck pain, any radiating pain down the arm, any bowel or bladder complaints, any fasciculations, any diplopia, dysarthria, dysphasia or breathing problems. He has no complaint of any persistent tingling or dysesthesias or numbness in his extremities. No aphasia. The disuse of his left arm has caused many problems that have led to a variety of psychiatric and social manifestations outlined in his past medical history and social history. He has had no prior problems with weakness, clumsiness.

PAST MEDICAL HISTORY:
1.  CABG.
2.  Hypercholesterolemia.
3.  Abdominal aortic aneurysm repair.
4.  Hernia repair.
5.  Right eyelid ptosis.
6.  Hospitalization in a psychiatry unit.
7.  Vertigo.
8.  Right neck paraesthesias and face paresthesias.

REVIEW OF SYSTEMS:  No diabetes. No hypertension. No pseudobulbar affect symptoms. History of immunodeficiency. No tremor.

CURRENT MEDICATIONS:
1.  Aggrenox 1 tablet b.i.d.
2.  Effexor XR 75 daily.
3.  Flomax.
4.  Lipitor 20 daily.
5.  Remeron.
6.  Ambien.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  He is a nonsmoker. He does not drink.

FAMILY HISTORY:  Mother died in her 80s with Parkinson disease. Father died in his 70s from natural causes. He has 2 brothers and a son, healthy. There is no neuromuscular disease in his family.

PHYSICAL EXAMINATION:  Blood pressure is 128/74, pulse is 72 and regular, respiratory rate is 18. Generally, the patient is a thin, elderly man. He is holding his left arm in upper motor neuron spastic manner. Carotids 2+ without bruits. Supple neck. Heart has regular rate and rhythm without murmurs, rubs or gallops. He is alert and oriented fully. He has no signs of aphasia or dysarthria. He gives his history well, but is reluctant to try to recall the details well and tries to rely on his family. When forced to give details, he can give them well. He names well, reads.

Cranial nerves:  Visual fields are full to confrontation. Left pupil is about 4 mm, right pupil is about 3 mm and both are equal, round and reactive to light. There is no APD. He has a right ptosis, which is at the pupil area. He has limited volitional right and left saccadic eye movements but can gaze in both directions when commanded to, and when his head is turned, he can maintain gaze to the opposite side. He has limited up and down gaze. He has symmetrically strong and full facial sensations, some facial smile, palate elevation, hearing to tuning fork. His right trapezius is full. His left trapezius is about 4+. His tongue has good bulk and has some fasciculations. It can move fully. Motor:  He has increased tone in his left fingers, wrists, biceps in a flexor manner. His right upper extremity has some paratonia to it. Both of his legs appear to have some increased extensor tone in a mild amount, more so at the knees. His strength in his left upper extremity allows him to mildly pronate and supinate at his forearm and about 4- strength to mildly extend and flex at his forearm and 4- strength to mildly flex all of his fingers and multiple joints at about 3/5 strength. He can abduct his thumb at about 3/5 strength. Other movements are not possible. His right upper extremity appears to have full strength. Bilateral lower extremities appear to have full strength. Reflexes, jaw jerk is absent. Grasp absent. He has a Hoffmann sign eliciting over his fourth left finger. His right upper extremity reflex is 2+. His left upper extremity reflexes are spread. He has 2+ at the side of knee; in his left ankle, it is 3+; in his right ankle, it is 2+ with toes upgoing. His left iliopsoas appears to have 5-/5 strength. Face is asymmetric. Sensory examination:  He reports full sensation to light touch, pinprick in his hands and feet. Vibration is mildly reduced at the left foot such that moderate vibration cannot be felt at the toes or midfoot. Joint proprioception appears to be full. Romberg, he has a nondescript sway in either direction. He does not fall. Coordination:  Right finger-to-nose appears normal. Right heel-to-shin appears normal. Left heel-to-shin was slightly clumsy. Gait:  He has a slow, somewhat wide-based gait with no arm swing in the left arm due to his weakness.

DIAGNOSTIC DATA:  He has had EMGs on two occasions. EMG examined his left median motor and sensory aspects and revealed mildly reduced left median motor amplitude at APB and stimulating of palmar area. He has no left median SNAP stimulating over the wrist. He had a normal EMG of his left upper extremity at that time. The second EMG was notable for decreased amplitude for left median motor. Again, absent left median SNAP and increased duration and polyphasic motor unit axial potentials on needle examination at the left APB with decreased recruitment. He also had decreased recruitment at left FDI. C-spine MRI in the last few months revealed C3-C4 and C4-C5 multifocal stenosis, some mild cord compression and there was multilevel foraminal narrowing at C3-C4 to C6-C7. A brain MRI with gadolinium in the last few months revealed periventricular changes and FLAIR signal in T2.

ASSESSMENT AND PLAN:  The patient is a (XX)-year-old gentleman who has had a progressive weakness in his left upper extremity over the past year and a mild weakness historically in his right distal upper extremity. His examination shows upper motor neuron pattern weakness in his left upper extremity. He also shows increased tone at all the four extremities, more brisk in the left upper extremity. He appears brisk with reflexes in the left upper extremity and at the left ankle. Multiple brain MRIs have not shown any acute sign of stroke. Cervical spine shows no contributing pathology that we could see. His presentation is more similar to degenerative problem of his corticospinal tracts. Possibilities such as HTLV-I, HIV, Lyme disease, myelopathy are possible but improbable.

We will screen for HTLV-I, Lyme disease, also check a B12, homocysteine, methylmalonic acid and routine laboratories. We think this is a neurogenetic problem affecting upper motor neurons but cannot be more specific at this time. We asked that the patient have his blood drawn today and that we will see him in followup within the next 2 months. We have told the patient we want to hear of any markedly worsening signs of weakness, dysarthria, dysphasia or breathing problems.

Thank you for allowing us to be involved in the care of this patient. We will see him in followup.


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