DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: We are seeing the patient in neurological followup. The patient is an (XX)-year-old female with several problems.
1. Evaluation in the past for left-sided tremor. Tremor did not appear to be consistent with a diagnosis of either Parkinson disease or essential tremor.
2. Behavioral changes.
HISTORY OF PRESENT ILLNESS: A chart review reveals the patient was last seen and evaluated by Dr. John Doe in the past for a complaint of behavioral changes. The patient’s son had contacted the office stating that he felt that his mother was very forgetful. Son stated his mother was not having any hallucinations. Son also reported that he felt the patient was becoming verbally abusive with the family.
For this reason, Dr. John Doe ordered several diagnostic studies, including an MRI, which was unable to be tolerated by the patient. She had a CT of the brain, which was reported as normal. The patient had a complete dementia workup, including B12, TSH, BMP, RPR, monoclonal profile, and an EEG. All diagnostic studies were reported within normal ranges with the exception of both the RPR as well as Lyme titer.
The patient was subsequently seen and evaluated by Infectious Disease. It was felt that the patient’s positive RPR was a false positive related to the patient’s positive Lyme titer. She was treated by Infectious Disease for these complaints.
The patient did have an EEG performed. The patient does present in the office for review of these diagnostic studies. EEG was reviewed with Dr. John Doe. It was felt that this was a normal awake and drowsy recording.
The patient does present for followup today. She is accompanied to the office by her son; however, she requests that her son not be in the office with her during evaluation. She reports that she does not feel that she has any difficulties with her memory. She denies any episodes of getting lost while traveling to familiar places. She denies any episodes where she feels that she has forgotten the names of faces of patients previously familiar with her. She feels that at times her memory difficulties have been due to the amount of work that she is expected to do on a daily basis.
The patient does report one recent episode of dizziness and nausea and vomiting. She reports that she was treated by her primary care physician and provided with meclizine 12.5 mg. She is currently on this prescription. She reports no subsequent episodes.
PAST MEDICAL HISTORY: Notable for anemia; colon polyps; appendectomy; breast tumor, not felt to be cancerous; breast lipoma; isocoria; osteopenia; rheumatoid arthritis; nasal polyps; behavioral changes documented by psychiatry.
SOCIAL AND FAMILY HISTORY: Reviewed. No changes in the patient’s social or family history.
MEDICATIONS: The patient does not have a medication list with her in the office today. Review of medications on file includes calcium, multivitamin, and aspirin.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: General: The patient reports that her weight has been stable. Her PCP has advised her to lose some weight. Of note, the patient’s last BMP did show an elevated glucose level. HEENT: She reports one episode of dizziness with vertigo as previously described. Ears: The patient denies any difficulty hearing. No tinnitus. Eyes: The patient does wear corrective lenses. Her last eye exam was approximately two years ago. She was informed she had a cataract that was developing. Respiratory: Positive for episodes of shortness of breath. She has been seen and evaluated by Pulmonology for this complaint. Cardiac: Negative for chest pain or palpitation. Gastrointestinal: One episode of vomiting related to vertigo. She denies any ongoing difficulties with nausea or vomiting.
PHYSICAL EXAMINATION: The patient is a pleasant woman. She is in no acute distress. Her vital signs are blood pressure 142/76, pulse 76, and respirations 14. Skin is warm and dry. Nails without clubbing or cyanosis. She is normocephalic and atraumatic. Her right pupil appears slightly larger than the left, both are responsive to light and accommodation. Extraocular eye movements are intact. Oral mucosa is pink. Dentition is in poor repair. Palate elevates symmetrically. Her extremities are warm. No edema is noted. On neurological exam, she is alert and cooperative. Her thought process is coherent. She is oriented to person, place, and time. On motor exam, no rigidity is noted, no tremor is noted, and no bradykinesia is noted. No ataxia is noted on finger-to-nose. Strength is 5/5 and symmetrical.
IMPRESSION AND PLAN:
1. History of tremor. No tremor is noted in the office today. No bradykinesia is noted on hand movements or toe tapping.
2. Behavioral changes and report of short-term memory problems. Previous Mini-Mental Status was reported as normal. All diagnostic studies to date have been reported as normal. The patient was offered a course of formal neuropsychological testing. The patient does not wish to pursue this modality at this time. She was advised should she have any increased difficulties or change her mind and wish to pursue this in the future, this could be arranged for her. She expressed verbal understanding.
The patient will follow up in the office on an as-needed basis.
