Neurology Inpatient Note

Admission Information:
Admitting Date Discharge Date Admitting Consultant Attending Consultant
22-DEC-2022 11-JAN-2023 Dr. Abdulrazaq Albilali Dr. Sohila Alshememri

Background:

(Mr/Ms.) is a x-year-old (lady/gentleman) with background of:

Reason for Admission:

Admitted through (x) as a case of (x)

History of Present Illness:

Hospital Course:

Physical Examination:

Vital signs & measurements:

Blood Pressure Tmax
Heart Rate Weight
Respiratory Rate 36.3 °C Height
SpO2 BMI

General appearance:

Looks well; lying down on bed comfortably; not in distress or pain.

Looks of stated age; average body built; looks of normal color.

No signs of volume overload/depletion.

No skin lesions or lymphadenopathy.

Mental status & higher functions:

Conscious, alert and oriented to time-place-person

Attentive; was able to subtract 7 out of 100 (name days of the weeks forward and backward)

Registration and recent memory seemed intact; was able to recall 3 words after 5 minutes.

Speech was fluent; comprehension, naming, reading and writing (language intact)

No cortical signs (ex. aphasia, agnosia or apraxia, gaze preference, neglect.)

Cranial nerves (CN II – CN CN XII):

Pupils were equal about 4 mm in size, symmetric, round and reactive to direct and indirect
pupillary response. Normal swinging light reflex with no RAPD.

Visual acuity with Snellen chart: 20/20 OU (corrected)

Color vision with Ishihara test: 15/15

Visual fields intact with confrontation (finger counting)

Fundoscopic examination showed healthy disc with well-defined margins.

No ptosis, misalignment or eye deviation with primary gaze.

Full range of extra-ocular movements (EOM) with no restriction, pain or diplopia in all
directions.

No nystagmus. Normal saccadic movements with smooth pursuit.

Normal conversion and accommodation.

Normal conjugate vision and no INO.

Normal sensation over face (V1-V3); with normal bulk of masseter and temporalis. Good jaw
opening.
No facial asymmetry. Good facial expression with good power (frontalis, orbicularis oculi,
zygomatic, orbicularis oris, buccinator)

Normal hearing with finger rub. No lateralization.

No dysphagia or dysphonia. Symmetric soft palate elevation and uvula is central.

Good power of sternocleidomastoid and trapezius.

No tongue atrophy or fasciculations. No deviation with good power.

Motor examination:
Inspection:

Normal muscle bulk; no clear atrophy, fasciculations or hypertrophic nerves.

No abnormal movements.

Tone:

Normal tone with no spastic catch or rigidity in all limbs

Power:

Upper limbs
Action Right Left
Shoulder ABduction 5 5
Shoulder ADduction 5 5
Elbow Flexion 5 5
Elbow Extension 5 5
Wrist Flexion 5 5
Wrist Extension 5 5
Finger Flexion (DIP + PIP) 5 5
Finger Extension (MCP) 5 5
Finger ABduction 5 5
Finger ADduction 5 5
Thumb flexion/extension/AB-ADuction/opp 5 5

Lower limbs
Action Right Left
 Hip Flexion 5 5
Hip Extension 5 5
Hip ABduction 5 5
Hip ADduction 5 5
Knee Flexion 5 5
Knee Extension 5 5
Ankle Dorsiflexion 5 5
Ankle Plantarflexion 5 5
Foot Inversion 5 5
Foot Eversion 5 5
Toe extension 5 5

Sensory examination:
Pinprick:

Present and symmetric in all limbs with no sensory level or dermatomal distribution.

Temperature (cold):

Present and symmetric in all limbs with no sensory level or dermatomal distribution.

Vibration:

Upper limbs (Right: | Left: ). Lower limbs (Right: | Left: )

Joint position.

Normal in all 4 limbs.

DTR & pathological responses:

Upper limbs
Action Right Left
Triceps +2 +2
Biceps +2 +2
Brachioradialis +2 +2
Spreading +2 +2
Pectoralis -ve -ve

Lower limbs
Action Right Left
Knee (patellar) +2 +2
Crossed adductors -ve -ve
Ankle +2 +2
 Hoffman’s sign Negative
Plantar response Down going, bilaterally
Clonus Absent.

Coordination:
No truncal ataxia

Finger-to-nose: no dysmetria or intention tremor, bilaterally

Normal rapid alternating movement with no dysdiadochokinesia

Heel-to-shin: normal.

Romberg's sign: negative

Gait:
Normal stance and physiological gait with normal swinging of both arms.

Special tests:
x

Labs:

CBC w/ diff WBCs Hgb PLT

6.64 14.7 228

LFT ALT AST Albumin ALP GGT Bilirubin

16.4 18.6 38.3 77 19 10.9

Coagulation PT aPTT INR

14.5 35.2 1.06

RFT & lytes Sr Cr / BUN Cr Cl / eGFR Potassium Sodium

103 / 7.5 56 / 63 3.9 141
Chloride Corrected Calcium Magnesium Phosphorus
106.7 NA NA 1.13

VBG pH pCO2 HCO3

 7.43 38 23.2

Thyroid TSH Free T4

4.99 12.1

Lipid panel LDL Chol Trig HDL

3.71 5.16 1 1

Radiology:

Discharge Plan:

Discharge medications:

Outpatient workup:

Labs:

Imaging:

Follow-up:

Referrals:

Counseling:

Lifestyle modification, including diet.

Avoid triggers.

Discussed with Dr. , Attending Consultant & Dr. , Senior Neurology Residen
MoCA:
Item Score Comment
Visuospatial & 2/5 Was able to draw a clock but the hands were incorrect
executive Drew a 1-dimentional cube (square)
Could not connect numbers and letters in order
Naming 3/3
Memory -
Attention & 1/2 Could not repeat in order (forward)
calculation 1/1
0/3 Could not subtract 7 out of 100
Language 1/2 Could only repeat the first sentence.
0/1 Was able to name only 1 word (+ 3-person names)
Abstraction 0/2 Similarity between train-bicycle: train need petrol and bicycle require energy.
Similarity between watch-ruler: watch specifies time and ruler in a straight line.
Delayed recall 4/5 Remembered FACE with multiple choice cue.
Orientation 3/6 Was able to tell day, place and city but not date month and year.

Examination OD OS
Visual acuity 20/20 (with glasses) No light perception (NLP)
Color vision 14/15; no red desaturation N/A
Visual fields with confrontation No VF defect N/A
Light pupillary response No RAPD RAPD +2
Fundoscopy Circumferential halo optic disc Difficult to visualize but it seemed
edema (raised ill-defined margins) to be worse. There was raised
– grade 2 optic disc edema. margins of the nasal aspect and
Present venous pulsation. Vessels tortuous blood vessels but no
seemed obscuration.