Neurology Consultation Medical Transcription Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
CONSULTANT: John Doe, MD
REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed female with a history of hypothyroidism, who was admitted to the hospital last night with severe headache, sudden onset, localized to right frontoparietal area, radiating to the back. Neurological consultation requested for evaluation of the same. The patient reports having developed sudden headache on the right side, throbbing in nature, last night, localized to the right parietal and frontal areas, radiating to the back of the head and right side of the neck. It is severe associated with nausea, but no vomiting. The patient does report blurred vision and photophobia. No speech difficulties or any diplopia, dysphagia or any focal neurological symptoms. She denies any vertigo. She states that, later, she did have possible hyperventilation and also complained of numbness in the lips and fingers but that resolved. She was brought to the emergency room. CT of the head without contrast was reported as unremarkable. Her blood pressure in the emergency room was 192/102 and pulse 72 per minute. She was given a dose of Demerol, which did help her, and was admitted for further management. At this time, she is feeling much better. She still has the headache but not as bad as last night.
PAST MEDICAL HISTORY: Hypothyroidism, allergies, and intermittent bifrontal headaches from allergies in the past. She has no history of increased hypertension, diabetes, TIA, severe seizures or any cardiac disease.
MEDICATIONS: Synthroid and Allegra.
ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: She smokes 5 to 6 cigarettes a day. She drinks alcohol socially.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: General: The patient is a well-built female not in acute distress. Vital Signs: Her blood pressure today is 142/78, pulse 68 per minute and regular, and she is afebrile. HEENT: Examination unremarkable. Neck: Showed some muscle tenderness on the right side. Full range of motion. No carotid bruit. Heart: S1 and S2 normal. No murmur, gallop or rub. Lungs: Clear. Neurological: She is alert and oriented in all three spheres. Normal speech and language function. Memory is intact in all modalities. Pupils are 3 mm, round, and reactive to light and accommodation. No visual field defects. Extraocular movements are full. No nystagmus. She does have mild photophobia. No facial asymmetry. Cranial nerves are intact. Muscle bulk and tone are within normal limits. No evidence of any focal motor deficits. Sensory examination is unremarkable. Deep tendon reflexes 2+ and symmetrical. Plantar response is downgoing bilaterally. Finger-to-nose test did not show any ataxia. Gait not tested at this time.
LABORATORY DATA: Chemistry profile on admission showed sodium 136 and potassium 3.4. Glucose, BUN, and creatinine normal. Liver profile was normal. PT and PTT within normal limits. WBC 11,200, H and H 14.2 and 41.4, and platelets 350,000. CT of the head without contrast as discussed above and was reported as negative.
IMPRESSION:
1. Sudden onset of right parietal headache, nonfocal neurological examination, no signs of any meningeal irritation. Most likely etiology is vascular headache versus related to uncontrolled hypertension. Possibility of an intracranial lesion cannot be ruled out completely.
2. She does have mild cervical strain, mostly in the right side. This might contribute to headaches.
RECOMMENDATIONS: We will get MRI of the brain with contrast. MRA of circle of Willis was just completed. I will also get C-spine x-rays, ESR, and continue symptomatic treatment. We will continue to monitor closely.
Thank you, Dr. Doe, for the consult. We will follow the patient with you.
