She has had no further episodes of presyncope or syncope. She is trying to take fluid and salt liberally. Her tremor is present mildly and only intermittently. It is primarily in the right hand. She continues to do tai chi twice a week and works out on the treadmill twice a week.

She denies depression, hallucinations, delusions, cognitive changes, dysphagia, dysarthria, hypophonia, freezing of gait, falls, sensory changes. She has mild bladder urgency. She also has mild constipation, which improves with the Rancho recipe.

MEDICATIONS:
1. Sinemet 25/100 mg 1-1/2 tablets t.i.d.
2. Naltrexone 5 mg nightly.
3. Coenzyme Q10 1200 mg a day.
4. Vitamin C.
5. Vitamin D.
6. Melatonin.
7. DHEA.
8. Memory Essentials supplement.
9. Magnesium and calcium supplement.
10. Acetyl-L-carnitine.

OBJECTIVE: The patient is a pleasant, well-groomed woman in no acute distress. Blood pressure is 98/60, pulse 78, respiratory rate 18. Affect is appropriate. She has only slight facial masking and much better facial expression today than at last visit. Extraocular movements are intact. Voice is of normal volume. Myerson’s is absent. Tone in the neck is trace increased. There is slightly reduced shoulder shrug on the right. There is a moderate amplitude intermittent rest tremor in the right upper extremity, which is infrequently present and less than the last exam. There is just a slight action tremor in the right upper extremity as well.

She has mild rigidity in the right upper extremity scored as a 1 on the UPDRS scale. On the left, she has just slightly increased tone in the left upper extremity scored as a 0.5. She has very mild bradykinesia bilaterally scored as a 1 on the right and a 0.5 on the left. Toe tapping is intact bilaterally. She rises from a chair easily without using her arms. Posture is erect. There is slight re-emergent tremor in the right upper extremity when she walks. Arm swing is intact. Pull test is negative.

Autonomic reflex testing revealed orthostatic changes with tilt of the bed. Supine blood pressure during the test was 126/62. When head was tilted up, blood pressure initially reduced to 118/66 with a heart rate of 96. Seven minutes tilt up, her blood pressure was 112/68 with a heart rate of 96. She complained of nausea at that time. It was found that she had an abnormal autonomic reflex study with evidence of cardiovagal dysfunction. There was also mild abnormality in sweat noted. There was no evidence of postganglionic sudomotor sympathetic function or adrenergic cardiovascular function.

ASSESSMENT AND PLAN: This is a (XX)-year-old woman with Parkinson’s disease and orthostasis.
1. Parkinson’s disease: She has really been doing quite well with a slight increase in her dose of Sinemet, and we would like her to continue on Sinemet 25/100 mg 1-1/2 tablets t.i.d.
2. Orthostasis: Though she has been asymptomatic since I saw her last, she continues to have low blood pressures, and tilt table test does show evidence of orthostatic changes. Given the fact that the Parkinson’s disease and the Sinemet combined can conspire to lower blood pressure further and in the future she will likely need increase in her dose of Sinemet, we would like her to start midodrine. She will start at 2.5 mg in the morning and increase after 1 week to 2.5 mg in the morning and 2.5 mg at noon. She will follow up with me in four months.

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Neurology Consultation Transcription Sample #1

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

Neurology Consultation Transcription Sample #2

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

Neurology Consultation Transcription Sample #3

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.

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abasia

absence seizures

acalculia

acaudal

accessory nerve

acetylcholine

acoustic schwannoma

afebrile seizure

afferent nerves

Alzheimer dementia

Alzheimer disease

amplitude

amyotrophic lateral sclerosis (or ALS)

anencephaly

aneurysm

aphasia

apraxia

arachnoid foramen

arachnoid membrane

astasia

astrocyte

astrocytoma

ataxia

ataxic gait

atonic seizure

aura

autonomic nervous system

axon

axon reflex

Babinski reflex

Babinski sign

Babinski syndrome

bacterial meningitis

Bell palsy

blood-brain barrier

bradykinesia

brain stem OR brainstem

brain wave

brainstem astrocytoma

Broca aphasia

Broca convolution

Broca fissure

Brudzinski sign

bulldog response

cardioembolic stroke

carotid plexus

cauda equina

cephalalgia

cephalgia

cerebellar

cerebellopontine (or CP)

cerebellum

cerebral angiography

cerebral brucellosis

cerebral concussion

cerebral cortex

cerebral hemorrhage

cerebral palsy

cerebral poliomyelitis

cerebral ventricle

cerebrospinal fluid (or CSF)

cerebrospinal fluid analysis

cerebrovascular accident

cerebrum

cervical radiculopathy

clonic seizure

closed head injury

cognitive deficit

coma

comatose

community-acquired bacterial meningitis

convolution

corpus callosum

cranial nerves (I-XII)

craniostenosis

craniosynostosis

craniotomy

cystic encephalomalacia

delirium

delirium tremens (or DT)

dementia

demyelination

dendrite

dense hemiparesis

dense hemiplegia

diplegia

dopamine

dopamine agonist

dura mater

dyslexia

echoencephalography

efferent nerves

embolic stroke

embolism

encephalitis

encephalomalacia

encephalopathy

epidural hematoma

epilepsy

epileptic seizure

event recall

evoked seizure

expressive aphasia

festinating gait

fissure

flaccid paralysis

foramen

foraminal

fornix

fourth ventricle

frontal lobe

galea

galea aponeurotica

ganglia

ganglion

ganglionectomy

giant cell astrocytoma

glioblastoma multiforme

glioma

grand mal seizure

gray matter

Guillain-Barré polyneuritis

Guillain-Barré syndrome

gyri

gyrus

hemianencephaly

hemianopia

hemiparesis

hemiplegia

hemorrhagic stroke

Huntington chorea

hydrocephalus

hyperesthesia

hyperkinesis

hypophysis

hypothalamus

intrathecal

Jolly reaction

lacunar stroke

laminectomy

leptomeningitis

lumbar puncture

lumbosacral radiculopathy

median nerve

medulla oblongata

meningeal

meninges

meningioma

meningitis

meningomyelocele

microglial cell

mild dementia

monoplegia

motor impairment

MRA

MRI

multiinfarct dementia

multiple sclerosis (or MS)

myasthenia gravis

myasthenic reaction

myelin sheath

myelogram

narcolepsy

neuralgia

neurological deficit

neuron

neuropathy

neurotransmitter

new-onset seizure

normocephalic

occipital lobe

orthostatic syncope

palsy

paraplegia

paresis

paresthesia

parietal lobe

parietooccipital fissure

Parkinson disease

peripheral nervous system

petit mal seizures

pia mater

piloid astrocytoma

poliomyelitis

polyneuritis

pons

postictal paresis

quadriplegia

radiculitis

radiculopathy

residual hemiparesis

Romberg sign

Romberg test

schwannoma

sciatic nerve

secondary seizure

seizure activity

senile delirium

senile dementia

senile tremor

sensory ataxia

sensory evoked potential

sensory impairment

shearing injury

somatosensory aura

somatosensory evoked potential

spastic hemiparesis

spastic hemiplegia

spastic quadriplegia

spina bifida

staphylococcal meningitis

stellate astrocyte

stereotactic neurosurgery

stimulus

subclinical seizure

sulci

sulcus

sylvian fissure

sympathetic nerves

synapse

synapse loss

syncopal

syncope

tandem stance

TBI or traumatic brain injury

thalamic

thalamus

thecal

thecal sac

thrombosis

titubation

tonic-clonic seizures

t-PA (tissue plasminogen activator)

transient hemiparesis

transient ischemic attack or TIA

trephination

tuberculous meningitis

vagal

vagotomy

vagovagal

vasovagal epilepsy

vasovagal syncope

venous thrombosis

ventricle of brain

vestibular schwannoma

viral meningitis

visual reflex epilepsy

visuospatial

vocal cord paralysis

waddling gait

Wernicke aphasia

whiplash injury

white matter

wide-necked aneurysm

Wolf-Orton bodies

Wolman disease

woodcutter’s encephalitis

wormian bones

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