Neurology Consultation Transcription Sample For Medical Transcriptionists

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:

Jane Doe, MD

CONSULTING PHYSICIAN:

John Doe, MD

HISTORY OF PRESENT ILLNESS:

I am asked to see this patient with an unknown left temporal lobe lesion, readmitted from hospice.  He was originally admitted to this facility for what was presumed to be a CVA.  He made slow progress and was transferred to hospice.  He developed worsening mental status and was returned to an outside hospital where neurology was re-consulted.  Increased mass effect was noted on the CT at that time, and it was therefore thought that this was a hopeless situation, and he was transferred to hospice.  His original MRI was done MM/DD/YYYY and suggested tumor.  Stereotactic brain biopsy done MM/DD/YYYY showed only ischemic changes.  He did have his course complicated by DVT in August and then he was brought here after that.

He was discharged from the outside hospital in July on Tegretol and steroids, and he had a six-week increasing history of fatigue, aphagia and intermittent visual change.  He was seen by Dr. Doe on MM/DD/YYYY, and a repeat head CT, as above, showed increased mass effect.  The head CT report is available for review and shows decreased attenuation on MM/DD/YYYY in the left posterior parieto-occipital region, mild mass effect in the left lateral ventricle and effacement of the sulci over the left frontal and parietal convexities.  There was a pore in cephalic region that was likely an old insult, and there was another area of decreased attenuation in the medial temporal lobe on the left suggestive of infarct of indeterminate age.  During his stay in the hospice, his mental status improved and he was brought back here, as above, for further treatment.

On MM/DD/YYYY, MRI of the brain at the outside hospital showed diffuse white matter edema in the left temporal lobe extending into the left posteroparietal region.  There was focal cystic structure, which they mentioned in the CT report and called infarct.  Here, they were not specific as to its etiology.  There was ischemic change in the right cerebral hemisphere, and after contrast, there was abnormal enhancement in the left cerebral white matter in the temporoparietal regions.  This extended superiorly and was felt to cross the corpus callosum onto the left side.  There was enhancement of the cystic lesion in the medial left temporal lobe.  It was felt that this corpus callosum involvement would represent malignancy such as glioblastoma, and lymphoma was another consideration.

The note from hospice is not helpful and only states that biopsy was negative, as we know, and then he was sent to hospice on MM/DD/YYYY.  On admission, he opened his eyes there but did not have any other verbal responses.  Over the last several weeks, he has improved markedly with speech and movement and is able to feed himself, awake, but slow to respond.  He was brought here after that.

MEDICATIONS ON ADMISSION:

1.  Glucophage.

2.  Lanoxin.

3.  Azmacort.

4.  Senokot.

5.  Morphine.

ALLERGIES:

DILANTIN AND CEFAZOLIN.

SOCIAL HISTORY:

He is a widower with a son with mental retardation.  He has a history of COPD with no cigarettes for eight years.

FAMILY MEDICAL HISTORY:

Contributory for cancer of unknown type in his mother and diabetes in his father.

REVIEW OF SYSTEMS:

He had pain in the coccyx on review of systems, that information was from the family.  From the patient, there is no information available.

The patient was started on Prozac recently for presumed depression.

PHYSICAL EXAMINATION:

Temperature 97.1 degrees, pulse 99, respiratory rate 16 and blood pressure 104/67.

The patient is seen at 5 o’clock at night.  He is aphonic and nonverbal, hypomimic.  He occasionally attempts words, but they are unintelligible.  He could not repeat.  He follows simple commands and does best in contacts, also does best in procedural-type of command or commands involving the appendicular muscles.  He cannot follow two-step commands.  Totally apraxic; however, this is difficult to interpret in the face of poor sustained attention, extreme latencies of response and very slow cognitive processing.  He does appear to understand at least simple commands.  Reading was not tested.

Cranial nerve examination shows fundi unremarkable.  Pupils equal and reactive, widening in the right palpebral fissure with slight flattening of the right face.  The patient was apraxic for mouth opening but could mimic a demonstrated command and had no asymmetry of the palate.  Tongue was midline.  Neck was supple.  Carotids were unremarkable.  The rest of his cranial nerves are grossly intact including his fundi.

His motor examination shows equal strength with proximal weakness.  It is more pronounced in the legs than the arms.

He has trace reflexes in the ankles, 1 in the knees and 1 in the arms.  Toes are down or equivocal.  He has a positive grasp/release bilaterally, negative glabellar, mildly positive palmomental and increased jaw jerks bilaterally.

Rapid alternating movements are equal. He had no gross limited ataxia in reaching but was uncooperative or unable to cooperate with finger-to-nose, heel-to-shin.  Gait was not tested.

LABORATORY AND DIAGNOSTIC DATA:

Recent laboratories were unrevealing, except a low sodium of 129, which may be related to his use of Tegretol in the past, which he no longer is on.

An EEG report from MM/DD/YYYY, while the patient was on Tegretol, reportedly showed further frontal intermittent rhythmic delta activity, nonspecific and not localizing.

IMPRESSION:

A patient with multiple lesions in the brain, most prominent sounds like the left temporal lobe and left posteroparietal region with gross enhancement of the white matter in those areas, extending superiorly and crossing over the midline to the corpus callosum onto the right side.  There is extension downward into the left basal ganglia as well.  There is small vessel disease in addition and the etiology of this enhancement is unclear.

PLAN:
1.  Obtain more information:  We will get his MRIs from his previous hospital to review.
2.  We will consider a followup MRI in this patient given his last one was on MM/DD/YYYY.  It may be reasonable to repeat another one just to look for change in the next two weeks or so.  We will decide this after we see the films from his previous hospital.
3.  Give him a trial of Sinemet 25/250 and see if this arouses him and makes him more alert given the left basal ganglia injury.
4.  I would leave him off the Tegretol at this time and not repeat any more EEGs unless the patient clearly had a clinical seizure.

We will continue to follow him.

I appreciate being able to share in his care.  More testing may be suggested after we see the brain MRI

-------------------------------------------

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Syncope.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with a history of chronic low back pain status post surgery, hypothyroidism, depression, hepatitis C, who presented to the ED complaining of severe low back pain.  According to the patient, she has had severe back pain for quite some time now and she had a history of a fractured vertebra.  The patient reports that she lost her Medicaid and that she has been unable to follow up with her primary care physician; therefore, she has not had any prescriptions for pain medications.  The patient reports that her pain is becoming very intense in her low back and that is why she came in for evaluation.  The patient also complained of episodes of loss of consciousness.  She reported that she has been having episodes where she passes out with complete loss of consciousness for about 3 minutes.  She denies any diplopia, dysarthria, vertigo, weakness or numbness associated with these episodes.  The patient denies taking any medical help during or after these episodes.  The patient denies any seizure-like activity with these passing out events.  She denies any tonic-clonic activity.  She denies any incontinence, any postictal state.

PAST MEDICAL HISTORY:  As above.

ALLERGIES:  IVP DYE.

OUTPATIENT MEDICATIONS:  Acetaminophen.

PAST SURGICAL HISTORY:  Cholecystectomy and hysterectomy.

SOCIAL HISTORY:  The patient denies any regular use of drugs.  The patient reports that she was on disability but that she lost it and is trying to obtain it again.

PHYSICAL EXAMINATION:  Vital signs are stable.  The patient is awake, alert and oriented x3.  Speech is fluent.  Good comprehension.  Affect is flat.  Pupils equally round and reactive to light.  Extraocular movements intact.  Visual fields are full.  Face is symmetric.  Tongue is midline.  Palate is symmetric.  Motor:  Upper extremities, 5/5; left lower extremity, 5/5; right lower extremity, 3+/5.  The patient complains of severe pain upon elevating her right leg.  She states that this pain is in her back.  Reflexes are 2+ throughout.  Plantars are downgoing.  Sensory:  Decreased pinprick in the right lower extremity.  Gait:  Deferred.

DIAGNOSTIC DATA:  CT scan of the brain not available.

ASSESSMENT:

1.  Chronic back pain.  The patient with history of vertebral fractures and previous surgery, which is causing her a lot of pain.  Recommend treating her pain and referring to pain clinic upon discharge.

2.  Syncope.  The patient with history of syncope, which does not have any oral or postictal state associated with it.  The patient's syncopal events do not sound neurologic and are very possibly functional but need to rule out cardiac causes.

PLAN:

1.  Referral to pain management.

2.  Rule out cardiac causes of syncope.

3.  MRI of the brain.

Neuro Consult Sample Report

-------------------------------------------

DATE OF CONSULTATION:

MM/DD/YYYY

REFERRING PHYSICIAN:

John Doe, MD

REASON FOR CONSULTATION:

Stroke.

HISTORY OF PRESENT ILLNESS:

The patient is a (XX)-year-old female with a history of deafness, diabetes, hypertension, coronary artery disease, peripheral vascular disease and status post right toe amputation who presented to the ED status post a fall.  Apparently, the patient's family members found her lying down on the floor after a fall.  The family noticed that the left side of her body appeared to be weak.  The patient was brought into the ED for evaluation.  According to the patient's family, at her baseline, the patient uses both sides of her body equally and states that she has never had a stroke in the past.  It is very difficult to get any history or physical, as she is completely deaf and her family members have to interpret via sign language.  The patient's family state that the patient does not want to be here and that she is asking to go home.

PAST MEDICAL HISTORY:

As above.

OUTPATIENT MEDICATIONS:

1.  Celebrex.

2.  Clonidine.

3.  Glucophage.

4.  Oxycodone.

5.  Enalapril.

ALLERGIES:

No known drug allergies.

PAST SURGICAL HISTORY:

Fem-pop bypass and right toe amputation.

FAMILY HISTORY:

Noncontributory.

SOCIAL HISTORY:

The patient lives with family.  Denies any drugs, tobacco or alcohol.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Stable.  Blood pressure 180/106.

NEUROLOGIC:  Mental Status:  The patient is lethargic, but easily arousable.  The patient appears to follow simple commands.  Unable to assess speech.  Cranial Nerves:  Pupils are equal, round and reactive to light.  Extraocular movements appeared to be intact.  There is left nasolabial fold flattening.  Tongue is midline.  Palate is symmetric.  Motor:  Unable to test due to translation issues, but the patient has obvious left upper extremity drift and she is unable to clear the left leg from the bed as opposed to the right.  Coordination:  Unable to test.  Sensory:  Unable to test.

LABORATORY DATA:

CT of the brain shows encephalomalacia in the left cerebral hemisphere.  No evidence of bleed.  Glucose is 290.

ASSESSMENT:

Stroke.  The patient presents status post fall, now has left-sided hemiparesis.  Was unable to get a complete neurologic exam due to language difficulties.  We would like a MRI and MRA of the brain for further evaluation.  Will also like to check the results of carotid duplex and 2D echocardiogram.  Agree with antiplatelet therapy.  The patient is in need of physical therapy and occupational therapy evaluation.

PLAN:

1.  Check carotid and echocardiogram results.

2.  MRI and MRA of the brain.

3.  Agree with antiplatelet therapy.

4.  Physical therapy.

5.  Check LDL and start statin if LDL is greater than 80.  We will follow with you.




Comments