HISTORY OF PRESENT ILLNESS: History was obtained from the patient and also from the patient’s daughter. The patient is a (XX)-year-old right-handed female who was admitted because of worsening bilateral lower extremity edema, inability to walk, and also with history of mental status changes. The patient was found to have atrial fibrillation and atrial flutter. She was started on anticoagulation therapy. She was also treated with a diuretic. Her lower extremity edema has significantly improved, but she continues to complain of weakness in the legs.

According to the patient’s daughter, the patient had been having increasing weakness in the lower extremities for several weeks. Initially, she was using a cane, then a walker, and lately, she has been wheelchair bound. She denies any significant pain in the legs, back pain or headaches. She has control of bladder and bowel function.

Recent workup also revealed multiple liver lesions, possibly metastatic. The patient is to have further workup, including CT of the chest, abdomen, pelvis, mammogram, and also ultrasound-guided biopsy of the liver.

PAST MEDICAL HISTORY: Significant for history of diabetes mellitus, hyperlipidemia, osteoporosis, arthritis, and recently diagnosed atrial fibrillation.

MEDICATIONS: Zocor, hydrochlorothiazide, benazepril, Fosamax, glyburide, and Toprol-XL.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY: The patient was apparently living by herself. There is no history of tobacco, alcohol or illicit drug use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: A 12-point system review revealed no additional pertinent information except for what is reported in the history of present illness, including progressive edema of the lower extremities for the last several weeks, decreased appetite, and multiple falls.

PHYSICAL EXAMINATION:
GENERAL: The patient is an obese elderly female who is not in any apparent distress.
VITAL SIGNS: Blood pressure 114/46, pulse 64 per minute, respirations 20, and temperature 98.8.
NECK: Supple.
HEENT: Head is atraumatic and normocephalic.
CHEST: Clear.
ABDOMEN: Soft.
EXTREMITIES: There is moderate bilateral pedal edema. Peripheral pulses are present but poor.

NEUROLOGIC EXAMINATION:
MENTAL STATUS: The patient is alert and oriented. Speech and language are normal.
CRANIAL NERVES: Pupils are postsurgical bilaterally but reactive to light. Extraocular movements seem intact; although, upgaze is limited. Face is symmetrical. Tongue is midline.
MOTOR: Strength is 5/5 in both upper extremities. In the lower extremities, proximal strength is 4-/5 of hip flexors, 4/5 of knee extensors and knee flexors, 2/5 dorsiflexor on the right side and 0/5 on the left side. Plantar flexor is 4/5 bilaterally. Deep tendon reflexes are absent throughout. Tests of coordination are normal in the upper extremities but difficult to perform in the lower extremities. Gait could not be tested.
SENSORY: Sensations are decreased to pinprick and touch up to the ankles bilaterally. There is tenderness over both calves as well as over the fibular heads.

LABORATORY DATA: Recent labs were reviewed. B12 level, TSH, and serum protein electrophoresis is normal. BUN and creatinine are elevated. The patient is being followed by renal service for that.

IMPRESSION:
1.  Paraparesis, left side more involved than right. There is probably bilateral superimposed footdrop, left side worse than the right.
2.  Probable diabetic peripheral neuropathy.
3.  Possible metastatic lesion in the liver.
4.  Encephalopathy, which seems to have improved.

RECOMMENDATION:  Given multiple lesions in the liver, we recommend doing MRI scan of the brain with contrast and MRI of the lumbosacral spine to rule out metastatic disease. We will have physical therapy evaluate for paraparesis and also for AFOs. If above investigations are negative, may consider doing NC/EMG study of the lower extremities.

HISTORY OF PRESENT ILLNESS: The history was obtained from the patient’s wife at length. No old records are available, including records of recent hospitalization at an outside facility. The patient is apparently a poor historian because of dementia.

This is a (XX)-year-old right-handed gentleman who six days ago was admitted initially to an outside hospital and then transferred to another hospital after a car accident. His brain imaging studies revealed left parietal hemorrhage. According to his wife, the patient had an MRI scan of the brain, which revealed evidence of cerebral amyloid angiopathy. The patient has hypertension and stayed in the ICU for several days to control the blood pressure. On their request, the patient was transferred two days ago to rehab. From rehab, the patient was sent here on the same day to have vascular studies of the lower extremity for DVT, which was negative, but on his way back, he struck his head to the window of the ambulance. The patient underwent CT scan of the brain, which again revealed parietal parenchymal hemorrhage but no evidence of any acute bleed on the left side where he was struck.

For several months, the patient’s cognitive functions have been declining slowly. He has been noticed to have been confused and at times wandering. His blood pressure also has been fluctuating. His blood pressure medicines were being adjusted recently.

PAST MEDICAL HISTORY: As above. History of hypertension, history of recently progressive cognitive deficit, and he was started on Aricept for that reason.

CURRENT MEDICATIONS: Lisinopril, Zestril, Aricept, and Proscar.

The patient has no history of head trauma. He has no history of seizures.

FAMILY HISTORY: The patient’s father died of brain hemorrhage. His mother died of heart disease. He has one older brother who has Parkinson’s disease.

SOCIAL HISTORY: The patient smokes two to four cigarettes a day. He occasionally drinks alcohol. There is no history of illicit drug use.

REVIEW OF SYSTEMS: As per the history of present illness. No additional pertinent information was obtained.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed and well-nourished man, who is not in any apparent distress.
VITAL SIGNS: Blood pressure is 154/94, pulse is 74, respiratory rate is 20, and temperature 97.8.
NECK: Supple. There are no carotid bruits.
HEART: Rate and rhythm are regular.
HEENT: Head is atraumatic and normocephalic.
CHEST: Clear.
ABDOMEN: Soft. There is no peripheral edema.

NEUROLOGICAL EXAMINATION: The patient is awake and alert. He is oriented to person and time; although, he did not know the date. He is oriented to place, but he could not tell the room number or floor. Short-term memory is 1/3 at 5 minutes. Attention and concentration are mildly impaired. Speech is fluent.
CRANIAL NERVES: Pupils are equal and reactive. Visual fields on examination revealed left-sided visual field defect and visual extension on the left side. There is very mildly decreased left facial nasolabial fold. Tongue is midline.
MOTOR: There is no drift. Strength seems to be 5/5 in all four extremities. Sensations are intact to pinprick, but the patient has sensory neglect on the left side. Gait is unsteady. Attention and coordination are normal.

DIAGNOSTIC DATA: We reviewed the CT scan of the brain done two days ago and the findings are as described before. There is mild mass effect also.

IMPRESSION:
1. Subacute left parietal parenchymal hemorrhage. The location of the hemorrhage is not typical of hypertensive, but hypertension probably has contributed to the hemorrhage. Underlying etiology likely is cerebral amyloid angiopathy.
2. Cerebral amyloid angiopathy.
3. Mild to moderate dementia, also probably related to cerebral amyloid angiopathy.
4. Uncontrolled hypertension.

RECOMMENDATIONS: At this time, blood pressure control is of prime importance. We will review old records from outside hospital, which have been requested and are awaited. We will observe fall precautions and use restraints if needed. Continue physical and occupational therapy as well as gait training. We will continue the patient on Aricept and increase the dose in three to four weeks to 10 mg daily.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation for medical clearance for electroconvulsive therapy.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old currently in intensive therapy unit with worsening depression for the last year. She currently denies any suicidal or homicidal ideation. However, she has requested medical clearance for ECT. The patient did receive ECT in the past and had good response with that. This new request for ECT has already been okayed by two psychiatrists and this only required medical clearance at this time. The patient’s last ECT was approximately 15 years ago.

PAST MEDICAL HISTORY: Significant for depression, which is now recurrent, and panic disorder.

PAST SURGICAL HISTORY: Bilateral tubal ligation and polypectomy of the uterus.

SOCIAL HISTORY: The patient denies smoking, drug or alcohol use.

ALLERGIES: Refer to chart.

HOME MEDICATIONS: Cymbalta, Klonopin, and Risperdal.

FAMILY HISTORY: Father had a coronary artery bypass graft.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6, pulse 62, blood pressure 106/66, and respiratory rate 18.
GENERAL: The patient is alert and oriented x3, in no acute distress, thin, well nourished and well hydrated.
HEENT: Normal oral mucosa.
LUNGS: Clear to auscultation bilaterally with good air movement.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft and nontender. Positive bowel sounds.
EXTREMITIES: Without edema. No erythema.
BACK: Straight. No deformities. No flank pain.

CURRENT MEDICATIONS: In the intensive therapy unit included Klonopin 0.5 mg every noon and 1 mg p.o. at bedtime, Cymbalta at 90 mg p.o. daily, mirtazapine 15 mg p.o. at bedtime, and Risperdal 2 mg p.o. at bedtime.

LABORATORY DATA: White count 4.6, H and H of 13.2 and 39.4, and platelets 270,000. Sodium 138, potassium 4.0, chloride 102, CO2 of 26, BUN 14, creatinine 0.8, and glucose 90. Alkaline phosphatase 38, ALT 15, and AST 24. Pregnancy test was negative. TSH 0.892. RPR is negative.

DIAGNOSTIC DATA: Chest x-ray was negative. Thoracolumbar spine x-ray showed no fracture, no subluxation with disk space preserved. EKG done three days ago showed normal sinus rhythm. No ST changes and normal segment.

ASSESSMENT AND PLAN: This is a (XX)-year-old female with recurrent major depressive disorder needing medical clearance for electroconvulsive therapy. At this point, electrocardiogram and exam is within normal limits. Thus, we will give an okay for electroconvulsive therapy from our medical standpoint, especially as she is a nonsmoker with no chronic medical issues of cardiac or diabetes and has a normal electrocardiogram rhythm strip. The patient is a good candidate, especially as she has had a good response with electroconvulsive therapy previously.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who is being seen in consultation for second opinion of vertigo. The patient has been evaluated here in the past. There is a balance evaluation that was completed previously, which demonstrated some gait related issues with platform testing but no other obvious vestibular dysfunction. According to the patient, she recently underwent a similar evaluation, which again did not document any vestibular dysfunction.

Her symptoms are somewhat vague, but she refers to her symptoms as dizziness. This primarily, however, is a feeling of unsteadiness with a sudden onset of a tendency to fall or become unsteady. This generally happens, if she is bending or moving her head and neck. She may have had some episodes of isolated vertigo with true spinning sensation in the distant past, which were related to positional changes while rolling in bed, but this is not her current complaint.

She did have significant head trauma in the past requiring evacuation of cerebral hematomas. At that time, she may have also had significant trauma to her neck; although, no surgery was performed of her neck. These episodes can occur in waves. She has not found any specific triggers.

The patient denies any visual changes such as loss of vision or blurred vision or double vision, speech or language difficulties; although, at baseline, she has dysphonia which was also evaluated in the past here with no specific neurologic or otolaryngological explanation.

She has, at baseline, some left lower facial droop but that is not acute. She has not experienced any tinnitus or hearing loss or numbness or tingling or focal weakness, bowel or bladder changes. She denies any fevers or chills or chest pains or palpitations.

PAST MEDICAL HISTORY: As detailed above with questionable seizure disorder in the past related to head trauma but no seizures recently. She also has adult attention deficit disorder and hypertension.

CURRENT MEDICATIONS: Omeprazole, lisinopril, carbamazepine, acyclovir for a nasal lesion, dextroamphetamine ER, and cetirizine.

ALLERGIES: NKDA.

SOCIAL HISTORY: She is divorced. She does not smoke and occasionally has a glass of wine.

FAMILY HISTORY: Negative for neurologic disease. Her father died of unknown cancer at the age of 46 and her mother had colon cancer.

PHYSICAL EXAMINATION:  Blood pressure is 156/94 with pulse of 72 and regular, respiratory rate 12, and pain scale of 0. She is sitting comfortably in a chair, well groomed with normal affect. She has some dysphonia but that is her baseline. She is alert and oriented with no evidence of dysarthria or aphasia. There is no right-left confusion or finger agnosia. Concentration is intact and recall is normal.

Cranial nerve examination reveals normal fundi with sharp disk margins. Pupils are symmetric and reactive. Extraocular muscle movements are without nystagmus. Visual fields are full. There is a mild left lower facial droop, which is old with no facial weakness. Tongue is midline. Palate elevates symmetrically bilaterally. Hearing to bedside testing is normal. Shoulder shrug is normal.

Motor examination reveals no tremors or myoclonus or focal weakness. Cerebellar testing, finger-to-nose is normal. Her gait is normal, but when we asked her to move her head and neck side to side while walking, she quickly became unsteady but was able to correct also relatively quickly.

Sensory examination is unremarkable. Deep tendon reflexes are 2+ throughout, and toes are downgoing. There is no sensory level.

DIAGNOSTIC DATA: MRI of the brain as well as an MRI of the neck was reviewed. There is evidence of old injury with encephalomalacia in the left temporal and left frontal areas but no other abnormalities, especially none in the brain stem. Cervical MRI demonstrated moderate amount of stenosis in the middle of the cervical spine with some spurs. The spinal cord itself appears to be normal.

ASSESSMENT AND PLAN:  The patient may have cervicogenic disequilibrium. We believe that neck exercises would be the most reasonable approach to pursue. We do not believe additional testing will be helpful. This may continue to be a chronic problem for her, however, despite our best efforts. There is no evidence at this time that this is related to vestibular dysfunction. We educated the patient about the condition and told her we will be happy to see her again in the future on as-needed basis.

HISTORY OF PRESENT ILLNESS: We are seeing the patient in followup visit. He is a (XX)-year-old man with several problems.
1. Parkinsonism, most likely multiple system atrophy with camptocormia, Pisa syndrome. The patient responded well to high doses of L-dopa.
2. Enlargement of the ventricles of the brain, no benefit after large volume spinal tap in the past.
3. Fiber neuropathy.
4. Autonomic dysfunction.

We had not seen the patient for three years. He is coming in today with his wife and his daughter. In the interim, he had been seen by Dr. John Doe and also Dr. Jane Doe for question of myopathy. Dr. Jane Doe felt that the symptoms are not typical for myopathy. She recommended a possibility of repeat EMG and muscle biopsy, but the patient declined.

There have been several changes in the last three years. The patient’s gait deteriorated further. He is having more of a shuffling gait with multiple freezing episodes. He is using a walker or he holds onto the furniture. He reports no falls, but he is very cautious. He also lost significant amount of weight, approximately 40-50 pounds, within the last two years. He has a good appetite.

The patient denies any cognitive changes or visual hallucinations. He denies any swallowing difficulties. He denies any tremor.

PAST MEDICAL HISTORY: Notable for atypical parkinsonism, most likely multiple system atrophy; prostate cancer; hyperlipidemia; right-hand Dupuytren’s contracture; hypothyroidism; hypertension; neuropathy; enlargement of the ventricles, but no improvement after spinal tap.

MEDICATIONS: Sinemet 25/100 mg 3-1/2 tablets at 7:00 a.m., 2 tablets at 11:00 a.m., 2-1/2 tablets at 3:00 p.m., and 3-1/2 tablets at 8:00 p.m.; Sanctura; diazepam; Synthroid; aspirin 81 mg; Allegra; and calcium.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY AND FAMILY HISTORY: Reviewed and is unchanged from previous note.

REVIEW OF SYSTEMS: Notable for weight loss, urinary incontinence, constipation, problems with ambulation, insomnia. The patient denies any cardiovascular problems. Occasional cold hands. The rest of the review of systems is negative.

PHYSICAL EXAMINATION: On examination, the patient is a very pleasant man in no acute distress. He is sitting in the wheelchair. His blood pressure is 132/62, pulse 66, respirations 18. He has prominent choreiform dyskinesias in all four extremities. He also has orofacial dystonia with mild spasm in the platysma and jaw dystonia. He has hypophonic speech. He has decreased upgaze. His face is symmetrical. Tongue is midline. He has generalized bradykinesia rated as 1 on all tasks in the upper extremities, very symmetrical picture. He has bradykinesia in the lower extremities rated as 0.5. He does have pretty normal tone. He can stand up with problems; we had to help him. We were able to walk part of the corridor with significant problems. He was taking very short steps; he was not responding to verbal cueing. He also had Pisa syndrome with tilt of the trunk to the right side. He had mild antecollis.

IMPRESSION:
1.  Multisystem atrophy: He deteriorated quite significantly but still seems to have response to high doses of Sinemet. Because he is taking the medication every four hours, we would like to change it and give him same dose of L-dopa during the day, but every three-hour intervals. He will take the medication at 7:00, 10:00, 1:00, 4:00 and 7:00. He will take 2-1/2 tablets in the morning and 2 tablets, 2-1/2, 2-1/2, and 2 tablets. We are also adding Sinemet CR 25/100 mg at bedtime. He will start with 1 tablet and we might increase to 2 tablets. We might also try Azilect in the future to see whether it might help his freezing gait.
2.  Weight loss: Unclear etiology.

RECOMMENDATION AND PLAN:  As above. The patient’s wife will call us in approximately three weeks to report whether he had any benefit. He will be seen in approximately four months.

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.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Physiatric evaluation and management of the patient with multiple sclerosis and gait disorder.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed gentleman who is referred by his primary neurologist for physiatric evaluation of problems with gait and stance. The patient reports that he was only recently diagnosed with multiple sclerosis after what appears to have been symptoms for several years. He does not give a great history, but it appears that approximately five years ago, after he suffered a right ankle fracture, he had a very difficult recovery from this injury.

He apparently had difficulty ambulating for over five months and eventually was able to move on to a cane. He thinks that during that time, he was flexed forward quite a bit and leaning on a cane and thinks that might have resulted in his gait disorder. Regardless, he has had a progression of his trunk flexion and rotation as well as his impairment in walking over the past five years such that he has great difficulty even doing his daily activities.

The patient had radiographic studies, which showed demyelinating lesions throughout the central nervous system, including the brain, cervical and thoracic spine with and without gadolinium. There were no gadolinium-enhancing lesions. He was seen by Dr. Jane Doe, who did not find any evidence of optic nerve involvement. He says to me that he thinks the lower extremity weakness and gait problems are his primary symptoms with MS. He gets fatigued very easily. He can only stand for short period of time and then has to sit down for a while before he can get up and move around again. It takes him about an hour to do his morning activities of daily living. He does not have a lot of energy for much else, including working, because of the difficulty of his mobility and activities of daily living.

He does have some urinary urgency and frequency. He denies any swallowing and speech difficulties. He is not sure if he has noted any cognitive decline but thinks that he does not have as much interest in academic pursuits or work-related issues because daily activities are taking all of his energy.

PAST MEDICAL HISTORY: Multiple sclerosis, history of infertility, testosterone deficiency, BPH, hypogonadism, status post right ankle injury, history of Clostridium difficile, and history of xanthogranuloma of the nose.

ALLERGIES: No known drug allergies.

CURRENT MEDICATIONS: Vitamin C 1000 mg b.i.d., vitamin D 1000 international units daily, multivitamin, and simvastatin 10 mg at bedtime.

FAMILY HISTORY: Question of MS in his mother who died at age 80 and apparently had developed a neurologic problem.

FUNCTIONAL HISTORY: The patient is independent in all mobility without an assistive device and with all self-care activities. He does drive and does some housework and meal preparation. He also works part-time doing some work for his wife. They have one child. He does not smoke, drink or use recreational drugs.

REVIEW OF SYSTEMS: The patient reports loss of energy, pain in his right hip posteriorly, some pain in the arms and legs proximally, some right ankle pain from time to time, and occasional numbness in the feet bilaterally. Remainder of review of systems is negative.

PHYSICAL EXAMINATION: On general examination, the patient is a well-developed, well-nourished gentleman in no acute distress, appearing younger than stated age. Blood pressure is 136/80, pulse 72, and weight is 205 pounds. Pain score is 3/10 with bilateral left ankle pain and right lower back, buttock pain.

Examination of the spine reveals him to have significant scoliosis. His trunk is essentially in forward flexion, primarily at the hips, but slightly in the thoracic spine as well. His entire spine is shifted to the left with a mild rotational component. When given cues, both physical and verbal, he is able to correct most of the spine deformity. However, he states that he feels a strain when he tries to stand erect and more symmetric and his position of comfort is in this forward flexed, left shifted and rotated position.

It is difficult to tell if there is a leg length discrepancy, but the pelvis generally appears to be level. In the supine position, he is able to lie completely flat, although there is still a mild shift of the spine with slight pelvic obliquity in the spine position as well. Extremity examination reveals mild edema at both ankles. There is no calf edema, but there is slight tenderness in the left calf around the insertion of the Achilles tendon when compared to the right.

Range of motion is reduced in both the lower extremities, particularly at the hamstrings. Straight leg raising is only about 45 degrees bilaterally as a result of hamstring tightness. Hip flexion and external rotation is mildly reduced as well. He has decreased range of motion at both ankles for both dorsi and plantar flexion.

On neurological examination, he is awake, alert, and oriented. Mental status appears to be within functional limits. There is no problem with receptive or expressive language skills. Mood is good and behavior is very appropriate.

Cranial nerve examination today reveals extraocular movements to be full without nystagmus. Pupils are equal, round, and reactive to light to light and accommodation. He has slight asymmetry of the face with decreased nasolabial fold on the left compared to the right. However, there is no asymmetry with smile or with the patient puffing his cheeks. Tongue protrudes to midline. Palate elevates symmetrically. Shoulder shrug is intact.

On motor testing, the patient has essentially normal strength in both upper extremities to manual muscle testing. Lower extremity strength is essentially 4+/5 to 5/5 on the right and 4/5 to 4+/5 on the left. There is slight asymmetry with weaker left hip flexors, left hamstrings, and left tibialis anterior when compared to the right.

Coordination is reduced on finger-nose-finger testing in the left upper extremity with mild dysmetria; it is intact in the right upper extremity. Toe tapping is reduced in both lower extremities, but left side is slower and with less amplitude than the right side. Toes are upgoing bilaterally in Babinski testing. Deep tendon reflexes are somewhat hyperactive bilaterally, but there is no clonus at the ankles.

Sensation is reduced to pinprick in both lower extremities in a patchy distribution in the feet and lower legs. Joint position sense is intact at both great toes.

Gait is with postural problems and with a narrow base of support. There is decreased balance as a result of these two problems. The patient’s trunk is also quite weak. He had a great difficulty doing a bridge exercise in supine and was not able to pick up his shoulder off the examination table in attempting an abdominal crunch.

IMPRESSION: The patient is a (XX)-year-old gentleman with what appears to be primary progressive multiple sclerosis. He is also status post a right ankle injury and appears to have some degenerative changes in the left ankle as well perhaps related to chronic instability from weakness. His neurological examination reveals him to have more symptoms on the left compared to the right with decreased coordination and slightly greater weakness. His main problem, however, is his posture with significant trunk weakness.

RECOMMENDATIONS: The patient recommended physical therapy to work on his trunk and lower extremity strength and coordination. He was given a prescription for physical therapy twice a week for six weeks to work on bilateral lower extremity stretching and strengthening exercises, especially stretching of the bilateral hamstrings and Achilles tendons and strengthening of hip extensors, abductors, quadriceps and tibialis anterior bilaterally.

Prescription also asked for trunk flexibility and strengthening exercises both for flexors and extensors, as well as postural training. He was asked to start working on light aerobic exercise program with a stationary bicycle or an elliptical machine. He will also be receiving gait training to improve symmetry of gait and posture. He has agreed to do a home exercise program regularly to improve and maintain his functioning in these areas. Followup with us will be in about two to three months. The patient was seen for a total of 60 minutes with the visit beginning at 3 p.m. and ending at 4 p.m. Greater than 50% of the time was spent in education, counseling and coordination of care.

REASON FOR VISIT: Dizziness and vertigo.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of hypertension, migraines, thyroid disease, hyperlipidemia, who saw us two years ago for evaluation of Parkinson’s disease. However, at that visit, there were no signs of parkinsonism including no signs of bradykinesia, rigidity, postural instability, or tremor, and there was no evidence of cognitive decline to suggest Alzheimer as well. Since that visit, she says that she has been doing well. She continues to have some migraines, and her migraines are atypical in that they distribute with some left-sided numbness in the tongue, cheek, and arm on occasions, but they have been well controlled with Imitrex, and she has been migraine-free for the past two years.

However, she says in the past few months or so, she has continued to have left-sided numbness in her left lip, left cheek, and left arm and sometimes her left leg, not associated with migraines. These episodes last minutes and not more than half an hour. There are no signs of weakness and no other focal neurologic deficits at the time. They started to occur daily since May of this year and so her primary care physician ordered an MRI, which she had at an outside hospital one week ago, for the numbness on her left side to evaluate for stroke. The MRI images were done without contrast and were done without an MRA of her head and neck as well. There is evidence of small vessel ischemic changes and are difficult to view, but there is also a question of some DWI changes, which may be artifact but needed proper ADC, which is to correlate with those, and the small vessel ischemic changes seen did not correlate to the periventricular areas and sagittal images. After this MRI, she says that she felt funny and then woke up the next day in the morning and felt vertiginous, especially when she got up. She said she felt like the room was spinning, but denied any focal numbness, focal weakness, any trouble swallowing or any other deficits. She vomited x1 and went to the emergency department, and at that time, they did not do any further imaging but gave her a dose of meclizine, which improved her vertigo immediately and sent her home with taking meclizine p.r.n. if she would need it.

Since that visit, she had no further episodes of vertigo. She says occasionally she gets lightheaded, and this occurs usually when she is working in the kitchen, does not occur immediately when she sits up or gets up from a seated or lying position, usually resolves within seconds, and she has not passed out. She says that daily she continues to have this left-sided numbness of her left cheek, left lip, sometimes involving her left arm and left leg. She says that occasionally she takes Excedrin Migraine, which seems to relieve the symptoms. She also says that she is wondering if these symptoms are occurring more frequently because she is under more stress with anxiety in her life; however, she is not sure if that is the cause. She comes to us for further evaluation.

PAST MEDICAL HISTORY: Thyroid disease, hyperlipidemia, migraines, osteopenia, alopecia, and irritable bowel syndrome.

MEDICATIONS: Currently aspirin 81 mg daily, amlodipine 5 mg daily, Levoxyl 100 mcg daily, Evista 60 mg daily, meclizine p.r.n. for vertiginous symptoms, omeprazole 20 mg daily, and lovastatin 20 mg daily.

ALLERGIES: Sulfa drugs.

SOCIAL HISTORY: No smoking or alcohol use. She lives by herself. She is not married. She is retired. She maintains an active lifestyle.

FAMILY HISTORY: There is a history of strokes on her father’s side. There is no history of seizures or Parkinson disease or Alzheimer’s in the family.

PHYSICAL EXAMINATION: Orthostatic testing reveals, in a seated position, blood pressure 128/72; pulse 82; in a standing position, blood pressure 130/80 with a pulse of 86. General: No acute distress. Lungs are clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. S1, S2. No murmurs, rubs or gallops. HEENT: No carotid bruits. Neurologic Examination: Mental Status: She is alert and oriented to person, place, and time. Fluent speech. No neglect. Normal naming. Following three-step commands. She is able to do serial 7s without difficulty, and her recall is 3/3 items without cues. Her memory is intact. Cranial Nerves: Pupils equally round and reactive to light. Visual fields are full to confrontation. Extraocular muscles are intact with no evidence of nystagmus. Facial sensation is intact to light touch throughout and temperature throughout. Facial muscles move symmetrically. Tongue protrudes midline. Motor Exam: Normal bulk. Normal tone. Strength is 5/5 throughout with no evidence of a pronator drift. Cerebellar: Finger-nose-finger testing reveals no signs of dysmetria. Gait is normal tandem walk. Reflexes are 2+ throughout with downgoing toes bilaterally.

ASSESSMENT AND PLAN: This is a (XX)-year-old female with a history of hypertension and migraines, who comes in to us today with complaints of left-sided lip, cheek, occasionally left arm or left leg numbness that has been occurring daily. The patient also had a self-limited isolated episode of vertigo one week ago, resolving with meclizine. Given her stroke risk factors of hypertension and hyperlipidemia, it is possible these episodes are due to transient ischemic attacks or strokes, and we recommend a repeat MRI of her brain with proper DWI and ADC correlating images. We would also like this MRI to be done with gadolinium, as these could be episodes fluctuating sensory deficits due to possible multiple sclerosis. Also, in the differential, these episodes could be simple partial seizures with preservation of consciousness. However, the MRI with gadolinium will give us a better understanding if there is any structural abnormality that may predispose her to seizures. We would also like to take a look at her head and neck vessels, and we recommend an MRA of her head and neck to evaluate her cerebral and extracranial vasculature. It is possible that these episodes may be due to stress and anxiety in her life. However, we did hyperventilate her about 1-1/2 minutes, and these did not reproduce the symptoms of left-sided numbness in her left cheek or her left arm. Therefore, we will defer this as a diagnosis of exclusion after further studies are undertaken. We would like to follow up with her after these studies are completed.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation of bilateral hand numbness and left forearm and wrist pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant male who was seen in consultation for evaluation of bilateral hand numbness and left forearm and wrist pain. Over the past year or so, he has had intermittent numbness and tingling to both hands that has awoken him from sleep. This goes away after a brief period of time. However, recently, as of approximately two weeks ago, he had sudden and extreme pain into the left side. They woke him from sleep and then failed to improve for over 2 to 3 hours. This involves principally his long and ring finger. However, since making the appointment, the patient’s symptoms have markedly resolved, and currently, he has no disability or pain. The patient denies any numbness or tingling. He did wear a carpal tunnel-type splint at night about a week ago, and this dramatically helped his numbness and tingling. He has also reported some forearm tightness bilaterally, some left wrist pain, in addition to some thumb pain in the past. He is concerned about circulation into his hand, stating that he was swimming off of a beach last year, where he came out of the water with his hands numb and tingling, and this persisted for several hours. He reports having had some tingling in both feet. This is mainly after sitting in a strange position for a long period of time, and currently, this is not really symptomatic. The patient denies neck pain and denies any recent injury. As part of his job, he uses his hands and arms continuously in addition to using vibratory instruments.

PAST MEDICAL HISTORY: Unremarkable.

PAST SURGICAL HISTORY: He has had prior left knee reconstruction.

MEDICATIONS: The patient takes amitriptyline.

ALLERGIES: He has no drug allergies.

SOCIAL HISTORY: The patient is married. The patient does not smoke and drinks occasionally.

PHYSICAL EXAMINATION: The patient is a very pleasant, articulate, healthy-appearing male, in no distress. His cervical neck motion is without pain. Elbow, hand, and wrist motion are full. He has positive Tinel’s over both carpal tunnels. Positive Tinel’s over both cubital tunnels. No tenderness over the pronator bilaterally. Markedly positive Tinel’s, just proximal to the transverse carpal ligament on the left wrist. No masses, warmth, or erythema noted. He has no pain with a resisted wrist flexion or wrist extension. No pain with resisted forearm pronation and supination. He is nontender over the medial or lateral epicondyle on either elbow. There is no evidence of ulnar nerve subluxation. A positive elbow flexion test under 30 seconds bilaterally. Positive Phalen’s maneuver, the left side 20 seconds, 30 seconds on the right. There is no evidence of thenar or hyperthenar atrophy. There is no intrinsic atrophy. Negative Wartenberg’s sign and negative Froment’s sign. No objective findings of decreased sensation. His hand is well perfused. He does not report having had any color changes with cold exposure or with any of his paresthesias. Motor strength is 5/5. Thumb is nontender. Wrist is nontender.

IMPRESSION AND PLAN: By history and partly clinical examination, his findings are consistent with cubital tunnel syndrome and carpal tunnel syndrome, left greater than right, and that is mild on both sides. Currently, he is minimally symptomatic. We discussed the pathophysiology of each. We have recommended nerve gliding exercises, extensor and flexor forearm stretching exercises. If his symptoms were to return simply, wrist braces at night or during the day such as driving can be helpful. Also discussed the role of cortisone injections if his symptoms were to worsen. Regarding his elbows, he will avoid leaning on the elbow or keeping it flexed for periods of time. If he developed further numbness into both hands or any involvement in his feet, we would recommend an EMG and nerve conduction studies and a probable neurology consultation to look for more intrinsic causes. At this point, he will follow up as needed given his relative lack of symptoms today. He is pleased with this disposition and will call if changes arise.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation and management of left leg weakness.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who has been treated for lower extremity weakness in the past post an AAA repair. The patient also has chronic pain management issues with low back pain, has had a previous workup for this. The patient was in chronic pain management physician’s office and was found to have left lower extremity quite cooler and with decreased pulses. The patient was advised to call Dr. John Doe who advised the patient to come to the emergency department. The patient’s wife is at bedside and wife and patient describe a progressive weakness in the left lower extremity that has gotten more difficult over the last month, and the patient is now having difficulty even ambulating with a walker short distances.

PAST MEDICAL HISTORY: Chronic low back pain, chronic left lower extremity weakness, diabetes, COPD, benign prostatic hypertrophy, history of alcoholism, coronary artery disease.

PAST SURGICAL HISTORY: Transurethral resection of the prostate, AAA repair, esophageal dilatation, and percutaneous coronary artery grafting.

ALLERGIES: MORPHINE.

CURRENT MEDICATIONS: Protonix 40 mg every day, cephalexin 500 mg every day, Restoril 15 mg at bedtime, Flomax 0.4 mg at bedtime, enalapril 5 mg b.i.d., Lopressor 25 mg b.i.d.

SOCIAL HISTORY: The patient lives with his wife and has remote alcohol and tobacco use. No drug use.

REVIEW OF SYSTEMS: The patient has had chronic back pain and left lower extremity weakness, but the patient is now having more difficulty with spasms and tone. The patient is unable to walk any distance and short distances are even getting more difficult. The patient is unable to ambulate without assistive devices. The patient denies any upper extremity weakness. The patient denies any difficulty with his eyesight. The patient denies any balance problems. The patient denies any headaches. The patient denies neck pain. The patient denies shortness of breath or chest pain. The patient denies any recent fevers or illnesses. For all other review of systems, refer to history and physical.

PHYSICAL EVALUATION:
VITAL SIGNS: Temperature is 97.6, pulse is 52, respirations 18, and blood pressure is 162/72.
GENERAL: This is a thin, Hispanic male.
HEART: S1, S2 normal. Pulses are present in all extremities. There is no cyanosis. Skin is warm. There are no carotid bruits.
LUNGS: Clear.
NEUROLOGIC: The patient is alert and oriented to person, place and time. Speech is fluent. Language is intact. Short-term and long-term memories appear adequate. Cranial Nerve Exam: The patient’s pupils are equal and reactive at 2 mm and brisk. EOMs intact. Visual fields are intact. Accommodation is intact. Corneal reflex is intact. The patient has a slight right nasolabial flattening. Tongue is midline with good palate elevation. Motor exam reveals bilateral upper extremities to be 5/5, the left lower extremity to be 2-1/2 out of 5 and the right lower extremity to be 4/5. The patient has upgoing toes, greater on the left than on the right. Has no clonus. Has increased spasticity in the left lower extremity. Deep tendon reflexes are +3 in both lower extremities and +2 in the upper extremities. The patient’s gait with walker is shuffled with a tendency to drag the left lower extremity and inability to bend at the knee in a standing position. Sensory exam reveals bilateral stocking distribution to mid calf to pinprick in both lower extremities and decreased proprioception in bilateral feet.

LABORATORY DATA: WBC 10.8, hemoglobin 12.4, hematocrit 37.8, and platelet count 192. Sodium 140, potassium 4.5, chloride 104, CO2 of 28, glucose 142, BUN 46, creatinine 1.6, and calcium 9.6. Liver functions are within normal limits.

IMPRESSION: Gradually progressive, left greater than right, lower extremity weakness suggestive of spasticity and upper motor lesion.

PLAN: We will do an MRI of the brain and C-spine. Will check B12 and RPR levels. Physical therapy to evaluate and treat.