Medical Transcription Chapter 14 Transcription 7
CHIEF COMPLAINT
Balance problems.
HISTORY OF PRESENT ILLNESS
This patient is a 54-year-old woman who complains of swaying when she is standing or even sitting for long periods. She loses her balance when she is standing to wash the dishes or brush her teeth or fix her hair. It does not matter if her eyes are open or closed, although it is much worse when she closes her eyes. This started at least as long ago as last spring and has been getting progressively worse. In the last couple of weeks, she has also had a feeling of light-headedness. Denies any diplopia, but it feels like her acuity has been decreasing over the last few months. She has never had an electromyogram (EMG), but they were working her up for a lumbar stenosis. She had an operation to release a tethered cord and also a fusion at L5-S1. They were hoping that she would walk better, especially with those, but she has not really improved any. She also had a somatosensory evoked potential, which showed abnormal bilateral tibials, somatosensory evoked potential in both the normal position and in the “Budda position.” Slowing of the central conduction is worse on the left than the right, but abnormalities are bilateral. She had an MRI of her spine--C-spine, T-spine, and L-spine--all of which showed no problems after her surgery except for post-op changes. She also had an MRI of her brain, which was normal. Patient says she does have some numbness and tingling, especially on her right side, upper and lower extremities, although occasionally on her left, that is becoming more frequent although still is intermittent.
ALLERGIES
No known drug allergies.
MEDICATIONS
She is on multivitamin daily and Premarin 0.625 mg daily.
PAST MEDICAL HISTORY
She had the back problems as above. Has migraine headaches since about 10. Has had about 4 in the last 2 years, not very frequent. She has a history of asthma. No other chronic problems.
PAST SURGICAL HISTORY
She had tonsillectomy, hysterectomy,
Balance problems.
HISTORY OF PRESENT ILLNESS
This patient is a 54-year-old woman who complains of swaying when she is standing or even sitting for long periods. She loses her balance when she is standing to wash the dishes or brush her teeth or fix her hair. It does not matter if her eyes are open or closed, although it is much worse when she closes her eyes. This started at least as long ago as last spring and has been getting progressively worse. In the last couple of weeks, she has also had a feeling of light-headedness. Denies any diplopia, but it feels like her acuity has been decreasing over the last few months. She has never had an electromyogram (EMG), but they were working her up for a lumbar stenosis. She had an operation to release a tethered cord and also a fusion at L5-S1. They were hoping that she would walk better, especially with those, but she has not really improved any. She also had a somatosensory evoked potential, which showed abnormal bilateral tibials, somatosensory evoked potential in both the normal position and in the “Budda position.” Slowing of the central conduction is worse on the left than the right, but abnormalities are bilateral. She had an MRI of her spine--C-spine, T-spine, and L-spine--all of which showed no problems after her surgery except for post-op changes. She also had an MRI of her brain, which was normal. Patient says she does have some numbness and tingling, especially on her right side, upper and lower extremities, although occasionally on her left, that is becoming more frequent although still is intermittent.
ALLERGIES
No known drug allergies.
MEDICATIONS
She is on multivitamin daily and Premarin 0.625 mg daily.
PAST MEDICAL HISTORY
She had the back problems as above. Has migraine headaches since about 10. Has had about 4 in the last 2 years, not very frequent. She has a history of asthma. No other chronic problems.
PAST SURGICAL HISTORY
She had tonsillectomy, hysterectomy,