SUBJECTIVE: The patient is an (XX)-year-old right-handed female who has been followed by Dr. John Doe for paresthesias of uncertain etiology. Her most notable complaint this visit is burning paresthesias in the left lateral thigh, which has been present for quite some time. She also notes a feeling of subjective swelling in the bilateral lower extremities, worse at night, but has never noted any objective swelling. She also gets full body paresthesias, which have been worked up extensively in the past without identified etiology. Workup in the past has included an MRI of the brain and spinal cord, EMG and nerve conduction studies both of which were normal. She does have a known history of an L5-S1 disk herniation and stenosis, which was mild on her last imaging study. She also has monoclonal IgG kappa gammopathy, which is followed annually by Hematology, of uncertain significance. Since her last visit, we did send her for autonomic testing due to concern for small fiber neuropathy. She did have patchy areas of abnormal spotting on QSART testing, which is of unclear significance. Her tilt table and cardiovagal testing was normal.
OBJECTIVE: Vital Signs: Heart rate 76, blood pressure 130/72, respiratory rate 14. General: She is a pleasant female who appears younger than her stated age. HEENT: Normocephalic. No nuchal rigidity. Cardiovascular: Normal S1, S2, regular rate and rhythm. No carotid bruits. Lungs: Clear to auscultation bilaterally. Neurologic: Mental Status: Alert and oriented to person, place, time, and situation. Fluent language with intact comprehension, reading, naming, and repetition. She was able to register 3 out of 3 words and recall 3 out of 3 at 5 minutes, 3 out of 3 with prompting. She is a good historian and is able to give accurate details of her recent and remote history. She was able to do serial 7s without difficulty. No left/right confusion, neglect, apraxia, or finger agnosia. Cranial Nerves: Pupils were equal, round, and reactive to light. Funduscopy revealed sharp disk margins bilaterally. Extraocular movements were intact without nystagmus. Visual fields were full to confrontation. Face was symmetric with full strength and sensation. Hearing was conversationally intact. Palate elevated symmetrically. No dysarthria. Sternocleidomastoid and trapezius, full strength. Tongue protrudes midline. Motor: Normal tone and bulk, 5/5 strength in all extremities. No pronator drift. Reflexes: 2+ in upper extremities, 1+ in the knees, trace at the ankles. Plantar response is flexor bilaterally. Sensory: Intact to light touch, pinprick, and vibration bilaterally. Coordination: No dysmetria on finger-nose, heel-to-shin, rapid alternating movements. Gait: She has a steady, narrow-based gait. She is able to toe walk, heel walk and do tandem gait. Romberg is negative.
ASSESSMENT AND PLAN: The patient is an (XX)-year-old right-handed female with multiple complaints but a quite benign neurologic exam and neurologic workup. Her most concerning complaint today is left side paresthesias consistent with meralgia paresthetica. We will refer her to the pain clinic for injection to help with symptomatic relief of her meralgia. Otherwise, we reassured her of the benign nature of her complaints and her reassuring exam. We will see her back on an as-needed basis.
SUBJECTIVE: The patient returns for followup of young-onset Parkinson disease. He was last seen in the office six months ago. In general, he is doing about the same. He thinks that perhaps his balance is a little off, though he has had no falls. He tries to stay active, going to the gym frequently, working on the treadmill and bicycling. He continues to take Mirapex and Artane, which help reduce his symptoms, especially his tremor. His tremor acts up if he is very anxious. He is tolerating the medications well without any sleep attacks, excessive somnolence, obsessive-compulsive behaviors, nausea, vomiting, orthostasis. He remains independent in all ADLs. He denies depression, anxiety, dysphagia, dysarthria, difficulty turning in bed, drooling, freezing of gait. He does have mild constipation and has noticed some hypophonia.
OBJECTIVE: The patient is a very pleasant Hispanic male in no acute distress. Blood pressure 126/86, pulse 82, and respiratory rate 16. He is alert and oriented to person, place and time. Affect is appropriate. He has facial masking, scored as a 1 on the UPDRS. Voice is slightly reduced in volume, scored as a 1 on the UPDRS. Extraocular movements are intact. Tone in the neck is scored as a 1 on the UPDRS. Shoulder shrug is reduced on the left. He has really very little tremor today, and there is just a slight shiver of tremor in the left upper extremity at rest. There is no postural or action tremor. He has just slight bradykinesia with finger tapping and opening and closing movements of the left hand, scored as a 1 on the UPDRS. Leg agility is scored as a 1.5 on the left. There is no bradykinesia on the right. His tone is scored as a 1.5 in the left upper extremity, 0.5 in the left lower extremity, and normal on the right. He arises from a chair without using his arms. Posture is just slightly flexed. When he walks, he has reduced stride length on the left and a little bit of a limp. Arm swing is mildly reduced on the left with a reemergent tremor on that side. Pull test is negative.
ASSESSMENT AND PLAN: This is a (XX)-year-old man with idiopathic young-onset Parkinson disease. He really looks to be doing quite well on his current medication regimen. We had a long discussion about his diagnosis and prognosis. We also discussed the ADAGIO study results, and we are recommending that he start Azilect 1 mg a day to help further with his symptoms but also for a possible disease modifying effect. We have given him a prescription for this medication. He should continue with his daily exercise, and we will schedule him for a followup in six months.
