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Neurology Medical Transcription Consult Sample Report




HISTORY OF PRESENT ILLNESS:  This (XX)-year-old female was admitted to the hospital last night for speech difficulties. Her husband reported that they were traveling. Her husband noted that she was not acting right for about 2 hours. She was unable to talk clearly and seemed to be confused. There was no complete loss of consciousness or any tonic-clonic seizure activity. There was no nausea or vomiting. No focal neurological symptoms reported. She was brought to the emergency room. Blood pressure was 225/115 with pulse 78 per minute.

CT of the head without contrast was reported as negative for any acute focal lesions. The patient was admitted for further management and started on heparin drip. This morning, she was still unable to give any history.

1.  Hypertension.
2.  Cardiac disease.
3.  History of shingles.
4.  No history of any transient ischemic attack, cerebrovascular accident or seizures.

1.  Vasotec.
2.  Zocor.
3.  Protonix.


SOCIAL HISTORY: No history of any smoking or alcohol abuse.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: General: The patient is a well-built, elderly female, not in acute distress. Vital Signs: As noted on the chart. HEENT: Examination unremarkable. Neck: Supple. No signs of meningeal irritation. No carotid bruit. Heart: S1 and S2 normal. No murmur, gallop or rub. Lungs: Clear. Neurologic: She is alert but she has expressive and sensory aphasia. She does not follow commands appropriately. She tries to utter words. At times, a few words are intelligible. Naming and repetition is impaired. Pupils are 3 mm, round and reactive to light. Extraocular movements appear to be full. No nystagmus. Mild right facial weakness noted, but facial movements could not be evaluated as the patient is unable to follow commands. Motor examination reveals normal muscle bulk and tone. She appeared to be moving all extremities spontaneously; however, on examination, there is mild weakness on the right side. Strength is probably 4/5 on the right. Sensory examination could not be evaluated accurately. Generalized hyporeflexia. Plantar response is upgoing on the right, downgoing on the left. Rest of the neurological examination could not be performed.

LABORATORY DATA: On admission, WBC 6100, H and H 14.2 and 44.4 and platelets 226,000. Baseline PT and PTT were normal. Chemistry profile showed sodium 135 and glucose 196. On admission, BUN was 25 and creatinine was 1.2. Liver profile was normal. Lipase was elevated at 509.

CT of the head without contrast is as discussed above.

1. Aphasia, expressive and also sensory component, possible mild right hemiparesis, most likely suggestive of left hemispheric cerebrovascular accident, carotid artery disease versus cardioembolic.
2. Hypertension and diabetes risk factors.

RECOMMENDATIONS: I agree with present workup and management. Repeat CT of the head without contrast tomorrow. Carotid Dopplers and echocardiograms were ordered. We will continue to monitor the patient closely.

Thank you, Dr. Doe, for the consult. I will follow the case with you.