DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is a (XX)-year-old who comes today for followup in Pediatric Neurology. He has a past history of spastic diplegia associated with prematurity. He also has migraine headaches. The patient was seen at the outside facility for his spastic diplegia but is seen here for his migraines.
The patient was last seen in Pediatric Neurology in March. He states that since that time, he has only had one migraine. It occurred on the first day of school. He stated that he did very well all day long until the last period when he developed the headache. He stated that initially his vision goes fuzzy and then he developed the headache with vomiting. He has medication to take, but he does not feel that it is particularly beneficial, so he usually just waits it out. By the next day, the patient was doing well. He stated that he still had a little bit of fuzzy vision but was much better.
Over the summer, the patient did see the ophthalmologist for his strabismus. According to the patient, the doctor stated that he could have surgery at any point, but if he wanted to wait until November that would be fine. Otherwise, the patient has been healthy. He is a junior in high school and does not have any specific concerns today, except that he is not gaining weight. He has not lost any weight but he is concerned.
CURRENT MEDICATIONS:
1. Relpax 40 mg to be taken at onset of migraine, may repeat in 2 hours one time only.
2. Ibuprofen 200 mg 2 tablets at onset of migraine.
3. Zofran ODT 4 mg tablet 1 tablet may be dissolved under the tongue upon the onset of migraine with nausea and vomiting. This can be repeated every 8 hours p.r.n.
OBJECTIVE:
VITAL SIGNS: Height 156.2 cm, weight 39.2 kg, pulse 78, blood pressure 118/60, temp 98.4.
GENERAL: The patient is a very delightful young man. He is bright, alert, and interactive.
NEUROLOGIC: Cranium macrocephalic. Cranial nerves II through XII are grossly intact. His pupils are round, equal, and reactive to light. He has full oculomotor movement. Strabismus is noted. He has a symmetrical facial grimace with normal-appearing tone, bulk, and movement. Cerebellar: There is no tremor noted when doing finger-nose testing. Rapid alternating movements are a little clumsy on the right. Motor: He has good muscle strength throughout. He does have mild increased tone noted in his heel cords and hamstrings bilaterally. DTRs are mildly hyperreflexic. Gait: He has a mild spastic diplegic gait but is able to walk independently. He can walk on his toes but has difficulties walking on his heels, particularly the right heel and has difficulties with tandem gait. Sensory intact to light touch. Spine: Straight without evidence of scoliosis.
ASSESSMENT:
1. Spastic diplegia associated with prematurity.
2. Migraine headaches.
PLAN:
1. At this time, because the patient has only had one migraine in six months, it is not recommended that he be placed on any prophylactic medication.
2. At this time, we will dismiss him from Pediatric Neurology. If he needs further refills on his medication, he can get that from his primary care provider. The patient does not think that the Relpax nor the Zofran helped tremendously, so he has not even been taking the p.r.n. medications.
3. Dismissed the patient from Pediatric Neurology. If at some point, his migraines worsen, we would be more than happy to see him back.
