Focused Neurological Exam (FNP, Summer 2022)
[date name="variable_1" default="05/27/2022"] [text area name="age" default="age"] [select name="variable_1" value="Male|female"] [text name="variable_1" default="race/ethnicity"] [remark]CC: [remark]HPI: [remark]EXAM: [remark]COMPLETED TESTING: [remark]A/P: [remark]PLAN: [remark]F/U: 05/25/2022 75 yo male with PMH of hydrocephalus s/p Right VP shunt (2019), HTN, HLD, and DM II presented to hospital on 5/23/2022 for worsening headache and dizziness. Neurosurg c/s resulted in shunt setting adjustment (concern for low pressure headache). Pt reports headache still present, but significantly improved since admission and denies any new problems or events overnight. Exam: AAOx 4, speech clear, some stuttering, no aphasia. VF intact, but pt reports vision changes in L eye that have improved along with headache. EOM intact, no nystagmus, Face: symmetrical, Tongue midline, neck supple. Gross motor: No drift of upper or lower bilat. extremeties, no ataxia. Motor: RUE 5/5, LUE 5/5, RLE 5/5, LLE 5/5. Sensation grossly intact. Patient had an MRI brain that showed no acute changes. LDL 150, HgbA1c 9.2, CTA Head and neck negative for vessel stenosis or occlusion, showed patent Right VP shunt. A/P: 79 yo male with migraine, unspecified, not intractable. Tests pending: none. Plan: continue home asa (81mg PO daily) + statin (Lipitor 20mg PO daily), medicine addressing elevated A1c and new DM diagnosis to be managed by medicine team. Consult placed to DM educator. F/U dispo: Establish new neurosurgeon (pt's recently retired)
There are 11 form elements.