Neurology Consultation Medical Transcription Sample Reports:
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old man who was seen in consultation for Dr. Doe for evaluation of possible stroke. This patient has a past medical history significant for diabetes mellitus, esophageal strictures, and cancer of the colon status post colostomy. He had been doing well until about two nights ago. He noted that he had some congestion of his left nasal passage and he could not clear it up. He tried to walk and suddenly his legs gave way on him. He felt dizzy and lightheaded and had to hold on to things to get to the bathroom. He went back to sleep and awoke the next morning with numbness of the left side of his face and lip. He tried to get up again and could not walk. In fact, he fell down and had an abrasion of his left arm. He also began to note some slurred speech and had difficulty swallowing liquids. His voice also became hoarse and had some blurring of vision. However, his symptoms seemed to improve, and presently, he still has continued dysphagia with some slurred speech, but his hoarseness of voice and vision is much better now. He did not have any acute upper or lower extremity focal weakness. He felt both of his legs were weak, and at present, his legs still feel stiff, may be possibly numb. He has not had any vertigo, chest pain, palpitations, shortness of breath, dyspnea, dyspnea on exertion, abdominal pain, nausea or vomiting.
ALLERGIES: NO REPORTED DRUG OR FOOD ALLERGIES.
MEDICATIONS AT PRESENT: Ecotrin 325 mg once a day, Tylenol, heparin IV, and atenolol.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Cancer of the colon status post resection.
3. Esophageal stricture.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Peptic ulcer disease.
7. Degenerative joint disease.
8. Right hip fracture.
PAST SURGICAL HISTORY:
1. Right hip surgery.
2. Partial bowel resection with colostomy.
3. History of esophageal dilatations.
FAMILY HISTORY: The patient's mother died at age of (XX). His father died of myocardial infarction at age of (XX). He has one brother who had a stroke. His sisters are well. Otherwise, no family history of diabetes mellitus, seizures, or psychiatric problems.
PERSONAL/SOCIAL HISTORY: The patient is married. He does not smoke. He denies any alcohol or drug abuse. He is originally from (XX) and used to be a (XX). He is retired.
REVIEW OF SYSTEMS: He denies any fever, cough, cold, headache, visual loss, diplopia, dysarthria or dysphagia. He denies hearing loss, ear pain, ear drainage, neck pain, chest pain, palpitations, shortness of breath, abdominal pain or acute problems.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure 136/88, heart rate 84, respiratory rate 22, and temperature 98.4 degrees. Weight 210 pounds. Height approximately 5 feet 8 inches. HEENT: Head is normocephalic. Conjunctivae are pink. Oropharynx is clear. Neck: Supple. There are no masses. There is no tenderness. Chest: Without any deformities. Abdomen: Soft and nontender without organomegaly. Extremities: Did not show any cyanosis or clubbing. Neurologic: Mental Status: He is alert and he is cooperative. Speech is dysarthric. Tongue is midline. He has good shoulder shrugs. Motor examination showed he had 5/5 strength in the upper and lower extremities. Back is normal. No gross ataxia was noted on finger-to-nose testing. Gait is not tested. The patient's visual fields are full. There was no facial numbness.
IMPRESSION: The patient is an (XX)-year-old man who has had transient numbness of the left side of his face and inability to walk. He now has some dysphagia and dysarthria. I suspect that he had a brainstem stroke. Etiology of this is probably secondary to small vessel disease, diabetes mellitus, hypertension, and possibly hyperlipidemia. Certainly, we can include other subcortical strokes that could be focal; however, at this point, it is very difficult to find more localizing signs.
2. Diabetes mellitus and hypertension as risk factors for stroke.
3. History of cancer of the colon, esophageal strictures.
PLAN: I would agree with his present management. We will keep him on heparin and aspirin. We will get his carotid ultrasound, echocardiogram, MRI of the brain, as well as MR angiography of circle of Willis and carotid arteries as well as the vertebral/basilar systems.
Thank you for allowing me to participate in this patient's care. We will be glad to follow him during his stay.
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old woman who was seen in consultation for Dr. Doe for evaluation of her change in mental status. This patient had been doing well and had been in good health until about a month ago, when she began to have sudden onset of numbness of her whole foot. She described it as a loss of sensation without any associated paresthesias or pain. There was no weakness and no radicular pain was noted either. She went to see a local podiatrist and was apparently given some hot compress without improvement of her symptoms. Her present problem began the day of admission. She apparently awoke very confused. She could not even recognize her husband. When she got up, she almost fell down. She did not notice it. The day before, she had some dizziness she describes as very lightheaded and at times vertiginous, especially if she bent over or tried to pick something up. Because of this, her husband called EMS, and by the time they got there, she was more alert and aware and did not have any focal findings. Her initial vital signs were blood pressure 139/74, pulse rate 82, respiratory rate 19, and O2 saturation was 97. Glasgow coma scale was 15. She was also complaining of feeling weak and was, prior to that, disoriented and confused. Otherwise, her examination was unremarkable. She was admitted and has been on telemetry; this has been negative. She does not have any symptoms or complaints at present otherwise.
ALLERGIES: NO REPORTED DRUG OR FOOD ALLERGIES.
MEDICATIONS: At present, heparin IV, Bextra, Clarinex, Ecotrin, K-Dur, Lasix, Lortab, and Protonix.
PAST MEDICAL HISTORY: The patient has hyperlipidemia, remote history of TIA, arthritis, and peptic ulcer disease. The patient denies any history of myocardial infarction, congestive heart failure or atrial fibrillation.
PAST SURGICAL HISTORY: The patient has had hysterectomy.
FAMILY HISTORY: Her father died of heart disease. Her mother died of old age. Two brothers died of cancer and one brother was alcoholic. Her sisters are well. There is no family history of seizures, strokes or psychiatric problems.
PERSONAL/SOCIAL HISTORY: She is married. She did quit smoking and drinking, so denies any alcohol or drug abuse.
REVIEW OF SYSTEMS: As noted above. She denies any fever, cough, cold, headache, visual loss, neck pain, chest pain, palpitations, shortness of breath, abdominal pain, new weakness, focal weakness, gait problems, or bowel or bladder changes.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure 160/68, heart rate 76, respirations 20, temperature 98.5 degrees, weight 138 pounds, and height approximately 5 feet 7 inches. HEENT: Head is normocephalic. Conjunctivae are pink. The oropharynx is clear. Neck: Supple. There are no masses and there is no tenderness. Chest: Without any deformities or tenderness. Abdomen: Soft and nontender without organomegaly. Extremities: Do not show any cyanosis or clubbing. Neurologic: Mental Status: She is alert and cooperative. Speech, language, and recent and remote memory are intact. Insight and judgment appeared very clear. Cranial Nerve Examination: Pupils are 3 mm and reactive to light. Extraocular movements appeared full without nystagmus. There is no facial weakness or numbness. Hearing is grossly intact to spoken word. Palate moves symmetrically. Tongue is midline. She has good shoulder shrugs. Motor examination shows that she has 5/5 strength in the upper and lower extremities. She had decreased light touch in the stocking distribution in both feet. Position sense is not tested. There is no gross ataxia of the upper extremities. Gait is not tested. Reflexes are +1. Ankle jerks are absent.
LABORATORY TESTS: CBC was normal. Sedimentation rate was 7. Chem-7 was normal. Ammonium level was 39. CRP is pending. PT and PTT were normal. Carotid ultrasound showed no hemodynamically significant stenosis. Urinalysis was hazy with 0-2 wbc's or none seen. Her initial PT and PTT were normal. CT scan of the head was also without any acute changes of supraventricular white matter/vascular disease changes.
IMPRESSION: The patient is an (XX)-year-old woman who presents with an acute episode of confusion. At this point, there is no clear source or etiology for it. This could include transient ischemic attack, probably in the vertebral-basilar distribution. Certainly, seizure cannot be entirely excluded.
PLAN: I would agree with the present management. I would get an EEG, get her carotid ultrasound, and repeat CT scan has been ordered. We will consider MRA and MRI as an outpatient. We will otherwise follow her during her stay. She has peripheral neuropathy, and we will obtain serologic tests for risk factors for stroke and neuropathy.
Thank you for allowing me to participate in this patient's care. We will be glad to follow her during her stay.
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