Neurology Sample Report #1
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is a (XX)-year-old man well known to us from prior evaluations for dementia. The patient’s last visit was three years ago. We had diagnosed the patient with early dementia, probable Alzheimer’s disease and started him on Aricept. Subsequently, the patient’s son determined that he was progressing very quickly, that he was unable to make decisions, and that he was at significant safety risk. He subsequently transferred his care to Dr. John Doe, who followed him for a period of 1-2 years. The patient was apparently switched from Aricept to Razadyne and now takes Razadyne extended release 24 mg daily. Dr. John Doe left his practice about a year and a half ago and care was then transferred to Dr. Jane Doe. Dr. Jane Doe started him on Namenda, and he takes 10 mg twice daily of that medication. The patient now wishes to transfer care back to us.
The patient stated that he feels he should be allowed to choose his doctors for himself and that he is satisfied with the care he has received here. Family members all report that he has been relatively stable on his current medication regimen. He is somewhat more forgetful and repetitive, according to his wife, but otherwise seems to be his usual self without significant behavioral or functional decline.
The patient’s son reported one or two occasions where the patient seemed to be reciting a conversation from the past. He was not unresponsive to suggest a complex partial seizure, nor was he hallucinating or delusional. On another occasion, the patient had awoken from sleep and seemed to be more confused as though still dreaming. Those symptoms lasted shortly.
There is no history of REM behavior sleep disorder-type problems. The patient has not had psychotic symptoms to date. Unfortunately, medical records from the outside facilities are not available for review today.
OBJECTIVE: On examination today, the patient appears casually dressed and groomed. He weighs 170 pounds. Blood pressure is 116/62, pulse 60, and respirations 16. Pain level is zero. He scores 21/30 on the mini-mental state exam using serial 7s. He lost points for orientation items, recall items, and the intersecting pentagon item. He does not have frontal release signs. He engages in conversation easily and fluently. He makes no paraphasic errors. He does not have frontal release signs. There is no agnosia or apraxia. His last exam here included a mini-mental state examination score of 27/30. The patient had already been experiencing some weight loss and loss of appetite after starting Aricept. There were no obvious extrapyramidal signs on today’s examination.
ASSESSMENT AND PLAN: In summary, this is a (XX)-year-old man with mild dementia, probable Alzheimer’s disease. He has declined a total of six points on the mini-mental state exam over a period of three years. This is below the average rate of decline suggesting that his current medications are helping to stabilize symptoms to some degree. There are no additional medications to offer at this time. The patient declined enrollment in a clinical trial for the time being. The patient agrees to following up every six months, and we will arrange a neurobehavioral examination at his next visit.
Neurology Sample Report #2
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient comes in for followup of dementia. The patient’s son is present. The patient is a (XX)-year-old woman with mild-to-moderate dementia, probable Alzheimer’s disease. The patient comes in today primarily for re-evaluation to fill out a medical certificate for guardianship. The patient has a long and well-documented course of poor judgment and impaired insight into her condition.
The patient’s son is gradually becoming more involved in her day-to-day affairs and offering her more assistance, but the patient persists in her efforts to continue driving. She did not recall ever having met me in the past. She did not recall any of the medication that she is currently taking without some reminder from her son.
The patient repeatedly requested explanations for the diagnosis of dementia and expressed limited insight into the nature of this illness. For example, she did not grasp the progressive nature of the illness, nor the necessity to have a plan to assist her once cognitive problems progress and worsen.
OBJECTIVE: On examination today, her vital signs are stable. She scored 18/30 on the Montreal cognitive assessment test. She has significant executive dysfunction, impaired construction, impaired working memory and impaired delayed recall. She is mildly disoriented. There are no frontal release signs. There is no agnosia or apraxia. Her gait is normal, and there are no significant extrapyramidal signs.
ASSESSMENT AND PLAN: In summary, again, the patient displays severe short-term memory problems impairing her capacity for decision-making. Although the patient shows an ability to have limited understanding of the diagnosis and her current situation, she quickly forgets this information and is unable to maintain a cohesive conversation regarding her future treatment and disability.
We do believe that she requires full guardianship to protect her. We do believe that she has displayed significant impairment of judgment putting herself and others at risk. The patient will return for additional monitoring of her cognitive status every six months. The patient will continue following up in Psychiatry Clinic as well.
