Neurology Study

EMERGENCY ROOM REPORT

HISTORY OF PRESENT ILLNESS

This child was born with cystic hydromas secondary to meningitis and has a permanent shunt in place.  The child has had increasing frequency of seizures over the past few months and has been treated in the emergency room and hospitalized on several occasions for these.  Today the patient requested that his mother pump his shunt and then began having left-sided seizures without vomiting or dyspnea.  He was brought to the emergency room by ambulance and had resolution of his seizure activity following approximately 5 minutes of seizure activity.  He had no incontinence at that time.  The child had had no flu problems and had a recent Dilantin level of 16.  He is currently on Dilantin Infatabs 50 mg, 3 in the morning and 2 in the evening.

LABORATORY DATA

Serum sodium 136, potassium 3.9, chloride 101, C02 28.  Glucose 100, Dilantin level 16.6.  The white blood count is 5900.  Hemoglobin 14.5, hematocrit 41.2, MCV 87, MCH 30.2.

ASSESSMENT

1. Acute focal seizure secondary to underlying seizure disorder.

2. Ventricular-peritoneal shunt appears to be functioning adequately.

Note:  CT scan performed 1 month ago documented this, and the shunt was pumped approximately 6 to 7 times.  There was good residual filling of this shunt.

PLAN

The patient is to be started on phenobarbital 15 mg q.i.d., i.e., 2 mg/kg per day.

FOOTNOTE

Line 8.  Alternative:  Hygromas.

Lines 27-29.  Enumerate the assessment for clarity.

Line 28.  Alternative:  Ventriculoperitoneal.

Line 32.  Alternative:  6-7.

Neurology Case Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSES

1. Closed head trauma, with persistent nausea and vertigo.

2. Preexisting homonymous hemianopsia.

FINAL DIAGNOSES

1. Status post closed head trauma (concussion), with spontaneous resolution of nausea and vertigo.

2. Cervical sprain.

3. Homonymous hemianopsia from postoperative stroke 1 month prior to admission.

HISTORY

A 67-year-old white man who was admitted following an automobile accident.  His car was apparently struck in the right front fender region by another car.  He apparently lost consciousness immediately upon the impact, and did not regain consciousness until the emergency medical technicians had already arrived, a time he currently estimates at 15 minutes.  He believes that he struck his forehead against his windshield, and probably against the rearview mirror as well, although not with great force.

Recent medical history is significant for hydrocele repair.  A few days following surgery, he developed homonymous hemianopsia.  Since then, he has been placed on aspirin.

PREADMISSION MEDICATIONS

Aspirin 1 t.i.d.  Stool softener 1 daily.

PHYSICAL EXAMINATION

Currently, approximately 16 hours following admission, lying in bed with soft cervical collar, in no apparent discomfort.  He has remained afebrile through his overnight stay, with stable vital signs.  Blood pressure has been approximately 160/90 this afternoon.  HEENT:  Tiny laceration over the right forehead, with mild swelling.  No palpable deformities.  Cardiovascular:  Regular rate and rhythm without murmur or gallop.  Carotids 2/2 without bruit.  No edema.  Toenails generally appear a bit clubbed, fingernails do not.  No cyanosis.  Neurologic:  Right visual field homonymous hemianopsia, which the patient reports is unchanged from prior to the accident.  Cranial nerves 2-12 otherwise intact.  Deep tendon reflexes 2+ at knees.  Toes downgoing.  Strength 5/5 throughout all extremities.   Coordination intact.  No Romberg sign.  Sensation grossly intact to light touch.

Cervical spine x-rays reportedly showed no fracture.  Head CT scan showed evidence of previous ischemic infarct in the optic region, but no new lesions nor acute bleeding.

Was admitted by the emergency room physician, and observed overnight, with frequent neurologic checks.  His nausea resolved by the morning following admission, and by the afternoon he was able to walk around without problem.

Is now being discharged, to continue use of cervical collar, usual aspirin, and stool softener.  He also has some oral pain medication on hand from his recent surgery, and he is to take this as needed.

CONDITION ON DISCHARGE

Good.

FOOTNOTE

Line 9 to end (Page 1).  The dictator said hemianopsia throughout; hemianopia is preferred in Dorland’s, hemianopsia in Stedman’s.

Line 23 (Page 1).  A comma, not the semicolon suggested by the physician, is the correct punctuation.

Line 35 (Page 1).  Exam was expanded to Examination in the heading.

Line 43 (Page 1).  Nor was changed to or to correct grammar.

Neurology Studies

INITIAL OFFICE EVALUATION

A 31-year-old black woman, neat and intelligent, but vague as to when symptoms started.  It was, she thinks, possibly 2 to
3 months ago that she first felt pressure behind her eyes, and she was seen in the eye clinic.  She thinks that it was about a week ago when she first noticed that if she looked off to either side, she saw double.  This has remained the same, and there is no longer a pressure feeling in her eyes.  She denies difficulty with mastication, deglutition, or use of extremities.

PHYSICAL EXAMINATION

The disks are flat.  One cannot be sure of the EOM weakness on observing the eyes in all of the cardinal directions of gaze; however, there is uncrossed diplopia on lateral gaze in either direction, indicating bilateral abducens muscle weakness.  On repetitive eye movements, there is minimal ptosis, slightly more on the left than on the right.  Other cranial nerves are intact.  DTRs 1 to 2+ and are equal.  Plantar responses are downward.  There is excellent strength and coordination in the face, neck, and extremity musculature, without evidence of fatigue.  No sensory deficits are present.

IMPRESSION

Patient apparently has bilateral abducens muscle weakness.  High on the list of possibilities would be myasthenia gravis and/or thyrotoxicosis.  An intrinsic brain stem lesion or a basilar skull fracture also must be ruled out.

Patient is to have skull x-rays, PA and lateral chest x-ray, T3, and 2-hour postprandial blood sugar.  A Tensilon test was attempted today, but patient has very bad veins, and enough Tensilon to carry out the test adequately was not possible to inject.  She is to return in a week for a Prostigmin test.

FOOTNOTE

Lines 7-38.  The physician dictates some inappropriate commas and semicolons, which were corrected.

Line 8.  Alternative:  2-3.

Line 14.  The physician mispronounces deglutition as deglutination.

Line 17.  Alternative:  Discs.

Line 23.  Alternative:  1+ to 2+.

Lines 31, 32.  The physician does not dictate fracture after basilar skull, but it was added for clarity.

Neurology Study

ADMITTING DIAGNOSES

1. Closed head trauma, with persistent nausea and vertigo.

2. Preexisting homonymous hemianopsia.

FINAL DIAGNOSES

1. Status post closed head trauma (concussion), with spontaneous resolution of nausea and vertigo.

2. Cervical sprain.

3. Homonymous hemianopsia from postoperative stroke 1 monthprior to admission.

HISTORY

A 67-year-old white man who was admitted following an automobile accident.  His car was apparently struck in the right front fender region by another car.  He apparently lost consciousness immediately upon the impact, and did not regain consciousness until the emergency medical technicians had already arrived, a time he currentlyestimates at 15 minutes.  He believes that he struck his forehead against his windshield, and probably against the rearview mirror as well, although not with great force.

Recentmedical history is significant for hydrocele repair.  A few days following surgery, he developed homonymous hemianopsia.  Since then, he has been placed on aspirin. 

PREADMISSION MEDICATIONS

Aspirin, 1 t.i.d.  Stool softener 1 daily.

PHYSICAL EXAMINATION

Currently, approximately 16 hours following admission, lying in bed with soft cervical collar, in no apparent discomfort.  He has remained afebrile through his overnight stay, with stable vital signs.  Blood pressure has been approximately 160/90 this afternoon.  HEENT:  Tiny laceration over the right forehead, with mild swelling.  No palpable deformities.  Cardiovascular:  Regular rate and rhythm without murmur or gallop.  Carotids 2/2  without bruit.  No edema.  Toenailsgenerally appear a bit clubbed, fingernails do not.  No cyanosis.  Neurologic:  Right visual field homonymous hemianopsia, which the patient reports is unchanged from prior to the accident.  Cranial nerves 2-12 otherwise intact.  Deep tendon reflexes 2+ at knees.  Toes downgoing.  Strength 5/5 throughoutall extremities.   Coordination intact.  No Romberg sign.  Sensation grossly intact to light touch.

Cervical spine x-rays reportedly showed no fracture.  Head CT scan showed evidence of previous ischemic infarct in the optic region, but no new lesions, nor acute bleeding.

Wasadmitted by the emergency room physician, and observed overnight, with frequent neurologic checks.  His nausea resolved by the morning following admission, and by the afternoon he was able to walk around without problem.

Is now being discharged, to continue use of cervical collar, usual aspirin, and stool softener.  He also has some oral pain medication on hand from his recent surgery, and he is to take this as needed. 

CONDITION ON DISCHARGE

Good.

FOOTNOTE

Line 9 to end (Page 1).  The dictator said hemianopsia throughout; hemianopia is preferred in Dorland’s, hemianopsia in Stedman’s.

Line 23 (Page 1).  A comma, not the semicolon suggested by the physician, is the correct punctuation.

Line 35 (Page 1).  Exam was expanded to Examination in the heading.

Line 43 (Page 1).  Nor was changed to or to correct grammar.

Neurology Case Studies

This 64-year-old man indicated that he was falling, he thinks, because he was off balance, seemed to fall forward.  There was some suggestion on exam that he had some mild parkinsonian symptoms, and since he was taking Reglan at the time, it was considered that he might be evolving side effects of Reglan, and it was recommended that this be discontinued and it was.  He indicates when he falls down now he cannot get back up and has to have someone help him.  Admits he has frequent dizzy spells, particularly when he first stands up.  Wife feels his speech has become slurred since this fall.  He says he does not think there has been any change in his speech with regards to slurring, but that he has had some trouble for a time now in trying to remember proper words to express his thoughts.  He denies any other problems with his memory.  Review of other neurologic symptoms reveals no significant problem with headaches.  He has lost vision in his left eye due to retinopathy and reports that his right eye now gives him difficulty, and it is hard for him to read.  He is not aware of ever having had any epileptic seizures.  His wife gave a history that he had had some swallowing problems recently.

PHYSICAL EXAMINATION

Physical exam revealed an alert, cooperative, oriented man who does not appear to be in acute distress at this time.  Intellectual function testing grossly suggests the patient may have some mild problems with memory, but he recalled me and my name when I first walked into the room, and he certainly is well oriented.  He is right handed.  Speech may be very slightly slurred.  No evidence of aphasia is noted.  Examination of the skull and spine is unremarkable.  Specifically there is no tenderness anywhere in the spine.  Neck vessels are unremarkable.

CRANIAL NERVES:  1:  Not tested.  2:  Visual acuity; right eye appears to be reasonably intact on bedside testing.  Left eye:  He cannot even see movement.  Right fundus only can be seen and shows changes of diabetes but otherwise unremarkable.  3, 4, and 6:  Movement of the right eye appears to be intact.  The right pupil reacts sluggishly to light.  There is no reaction of the left pupil.  5:  Normal motor and sensory function.  7:  There appears to be a very slight drooping of the left corner of the mouth.  8:  Hearing is grossly intact.  9 and 10:  Uvula is in midline.  Palate moves symmetrically.  11:  Sternomastoid and trapezius muscles appear to contract well.  12:  Tongue protrudes in midline.  Movements are intact.  No wasting.

MOTOR SYSTEM:  No deformities noted.  He has some significant wasting of the muscles of both hands.  On testing strength he has a mild to moderate weakness of the extremities, particularly distally and symmetrically.  Deep tendon reflexes are absent throughout.  He was noted at times to have some jerking myoclonic-type of movements in his upper extremities, particularly the left.  Patient was not gotten up to test stance or gait at this time.

SENSORY EXAM:  Has decreased pin sensation, stocking-glove fashion, up to about the wrists and the hands, to just about the knees and the legs.  This was for pain sensation.  Joint position sense appears to be intact.

IMPRESSION

The patient has a fairly severe diabetic neuropathy causing postural hypotension.  I suspect this is the major reason for his falling.  I certainly agree that an magnetic resonance imaging is indicated at this time to investigate for the possibility of recent cerebrovascular accident but suspect his peripheral neuropathy and postural hypotension are going to be the main causes of his difficulties.

FOOTNOTE

Lines 10-13 (Page 1).  The dictator’s awkward phrasing was edited.

Line 28 (Page 1).  Exam was expanded to Examination in the heading.

Lines 19 (Page 2).  The abbreviation MRI was expanded in the Impression for clarity.

Line 23 (Page 2).  Cause was changed to causes for plural agreement (neuropathy and hypotension are causes).