Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

NEUROLOGICAL CONSULTATION TRANSCRIPTION SAMPLE

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Progressive weakness of both lower extremities.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was referred because of progressive weakness of both lower extremities.  This patient was seen in the hospital for respiratory failure and exacerbation of her asthma.  The patient is diabetic and has been diabetic for two years secondary to use of steroids and she has been on steroids for many, many years.  When she was initially seen, she had weakness of both proximal and lower extremity muscles.  The lower extremity weakness was more profound.  The left was a little bit more worse than the right, and she had distal weakness in both upper extremities, more so than the proximal weakness, and in the lower extremities, she had moderate weakness, about grade 3/5 proximally.  She was telling me that she was walking with two steps, but since last week, she has noted that there is more tingling in her arms and in her feet and that she is no longer able to move her legs; she could no longer stand.  She is currently still on the same dose of steroids, of 40 mg.  She told me just before she was transferred, her steroid was up to 60 mg and then back down to 40 mg.  During her hospitalization at the previous hospital, she did have an MRI of the cervical cord that did not show any lesion or any compressive pathology.  She had a normal CPK, thyroid.  She had a Foley catheter then and this has been off since her transfer.  She knows when she has to go to the bathroom, but often times, she cannot make it to the bathroom because of the weakness and she leaks.  She has good bowel control.  Her sensory symptoms have progressed.  She denies any difficulty swallowing.  No visual complaints.

PAST MEDICAL HISTORY:  Significant for hypothyroidism, osteomyelitis, and olecranon bursitis.  She also has a history of deep vein thrombosis.

ALLERGIES:  SHE IS ALLERGIC TO PENICILLIN AND PAPER TAPE.

PERSONAL AND SOCIAL HISTORY:  She does not smoke nor drink and lives with her family.

PHYSICAL EXAMINATION:  GENERAL:  She is afebrile.  NEUROLOGICAL:  She is awake and alert.  She is weak on the left side.  She does have significant hearing deficit.  The optic disks are clear.  There are no visual field defects.  She moves her eyes in all directions.  There is no nystagmus.  The speech is clear.  The tongue is midline.  There is no facial weakness.  Motor examination revealed mild weakness of the deltoid, the biceps.  The triceps is about 4/5.  Distally, she has quite weak grip, about 3/5.  The left is weaker than the right.  In the lower extremity, all she is able to do is wiggle her toes and internally and externally rotate her hip, her legs.  Sensory examination revealed decreased pinprick sensation up to just below the umbilical area.  In the upper extremity, there is decreased pinprick sensation up to the mid arm level.  The vibration sense is absent in the toes, diminished in the fingers.  Position sense is absent as well in the toes, present in the fingers.  Her reflexes are present all over, including knee jerks, except for the absent ankle jerks.  She has got severe tremor in her upper extremity, both postural and with intention.  She could not get up, but she was able to take her pants off independently.

DIAGNOSES:
1.  Evidence of polyneuropathy, probably diabetic.  I doubt that this is Guillain Barre because of the severe weakness.  Her reflexes are still quite intact.
2.  Steroid myopathy.
3.  Diabetes, steroid induced.
4.  Severe asthma, steroid dependent.
5.  Tremor, probably related to weakness and asthma medication.

PLAN:  I am going to go ahead and re-scan her back.  She did have a cervical scan.  We will scan her back to be sure that there are no compressive symptoms, compressive pathology.  She will need a nerve conduction study, and I have asked Dr. Doe to do it in the hospital.  She might need a muscle biopsy.  If everything comes back negative, we will also do a spinal fluid analysis on her; although, clinically, she really does not have Guillain Barre because of the intact reflexes.  We will also do a brain CT scan and brain MRI.