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Epilepsy Consultation Doctor Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULT:  I saw the patient in consultation today for intractable epilepsy and left temporal cavernous angioma at the request of Dr. John Doe.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed woman.  Over the past 2 or 3 years, she began to have seizures. These seizures typically begin without warning and involve loss of awareness, speech arrest, and an arrest of activity. Sometimes there is lip smacking associated with it. On two occasions, she has had an epigastric rising sensation, but generally, they occur without warning. She has no recall for the event. The event lasts 30-60 seconds. Postictal, she is mildly confused and tired. She apparently does not have any significant language problem postictal. She does occasionally seem to understand and respond appropriately to spoken words during the event. She has never had a generalized tonic-clonic convulsion.

The patient has been tried on a variety of different medications and is currently weaning off Keppra and beginning on Topamax. She typically gets improved control with new medications and then the seizures return. They are now occurring about once every week; although, she had two yesterday. The patient was recently brought into the hospital for video EEG monitoring. Several seizures were recorded; although, they did not have EEG accompaniment. There were frequent interictal left anterior temporal spike discharges, however.

PAST MEDICAL HISTORY:
Positive for:
1.  Hypertension.
2.  Hyperlipidemia.
3.  Some heart disease.

MEDICATIONS:
1.  Topamax.
2.  Lisinopril.
3.  Hydrochlorothiazide.

ALLERGIES:
No known drug allergies.

PHYSICAL EXAMINATION:
On examination, the patient is alert and oriented with grossly normal cognition. Language comprehension and expression was quite normal. Pupils were equal and reactive to light and accommodation. Extraocular movements were full. There was no field cut. Facial sensation and symmetry were intact. Muscle bulk, power, and tone were normal bilaterally. There was no drift. Sensation was grossly normal. Gait and balance were normal. Romberg was negative.

DIAGNOSTIC STUDIES:
The patient’s MRI scan demonstrates a 1.5 cm heterogeneous lesion in the superior temporal gyrus on the left anteriorly. It represents a small cavernous angioma.

ASSESSMENT AND PLAN:
This patient has intractable complex partial seizures originating in the left temporal region. They are caused by the small superior temporal gyrus cavernous angioma. We do think that she would be an excellent surgical candidate, and we are going to make arrangements for resection of the cavernous angioma and small topectomy in the next several weeks.