Other forms of migraine without mention of intractable migraine without mention of status migrainosus Abnormal reflex
 
Name:  ___               ___ No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROLOGY
 
Allergies: 
Sulfa (Sulfonamides) / Penicillins
 
Attending: ___
 
Chief Complaint:
Facial weakness
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
HPI: ___ RHF w/ hx GERD, mild depression, and prior migraines,
presents now with episode of facial numbness. She had been lying
on her left face, watching TV, and noticed when she got up that
her left face was numb as if she were injected with novacaine, 
in
a distribution that she traces along mid-V2 down to her jaw 
line.
She initially thought it was ___ the way she was lying, but
became concerned when it persisted. She endorsed a mild diffuse
dull HA that is not unusual for her. She states in some ways, it
felt as though a migraine were coming on, though the HA she had
was not typical of her past migraines. The numbness lasted 90
minutes, and has now resolved completely. There was no 
associated
weakness, no sensory changes outside of her face, no VC, 
vertigo,
or language impairment. She cannot recall something like this
happening before, and states that her day was otherwise routine.
On ROS, she notes that about 2 weeks ago she had diarrhea for 1
week which resolved spontaneously. She also endorses feeling
"achey" 4 days ago, otherwise, her health has been normal. 

 
Past Medical History:
GERD 
mild depression
migraines (throbing HA's assoc with visual flashes of light),
last ___ years ago 
bunions
 
Social History:
___
Family History:
Father with HD, sustained a stroke after a cardiac cath. Later 
in
life father developed a meningioma and subsequent seizures. 

 
Physical Exam:
98.4F 69 134/79 15 100%RA 

Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa   
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs 
Lung: Clear to auscultation bilaterally 
aBd: +BS soft, nontender 
ext: no c/c/e; equal radial and pedal pulses B/L. 

 
Neurologic examination: 
Mental status: Awake and alert, cooperative with exam, normal 
affect.  Oriented to person, place, and date.  Attentive, says
___ backwards.  Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. Reading intact. No
right left confusion. No evidence of apraxia or neglect.
 
Cranial Nerves:  
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. Retinas
with sharp disc margins B/L. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1-V3 to both LT and
PP.  Facial movement symmetric.  Hearing intact to finger rub
bilaterally.  Palate elevation symmetrical.  Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
 
Motor: 
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
  Del Tri Bi  WF WE FE FF  IP  H  Q DF PF TE TF
R  ___  ___  ___  ___  5  5
L  ___  ___  ___  ___  5  5  

Sensation: Intact to light touch, pinprick, and proprioception
throughout. 

Reflexes: 
+2 and symmetric throughout.  
Toes downgoing bilaterally 
 
Coordination: finger-nose-finger normal, heel to shin normal, FT
and RAMs normal. 
 
Gait: Narrow based, steady. Able to tandem walk without
difficulty

Romberg: Negative

 
Pertinent Results:
___ 06:10AM BLOOD WBC-5.3 RBC-4.38 Hgb-11.5* Hct-36.1 
MCV-82 MCH-26.2* MCHC-31.8 RDW-13.3 Plt ___
___ 11:14PM BLOOD Neuts-52.1 ___ Monos-4.7 Eos-2.0 
Baso-0.5
___ 11:14PM BLOOD ___ PTT-33.7 ___
___ 06:10AM BLOOD Glucose-82 UreaN-16 Creat-0.8 Na-140 
K-4.0 Cl-105 HCO3-26 AnGap-13
___ 11:14PM BLOOD ALT-13 AST-19 CK(CPK)-69 AlkPhos-70 
TotBili-0.2
___ 11:14PM BLOOD CK-MB-NotDone cTropnT-<0.01
___ 11:14PM BLOOD TotProt-7.1 Albumin-4.5 Globuln-2.6 
Calcium-9.5 Phos-3.7 Mg-2.1
___ 02:26AM BLOOD %HbA1c-5.7
___ 11:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Radiology Report MRA BRAIN W/O CONTRAST Study Date of ___ 
9:44 AM 
1. No acute intracranial abnormality; specifically, there is no 
evidence of 
either acute or previous ischemic event. 
2. Normal cranial and cervical MRA, with no significant mural 
irregularity or 
flow-limiting stenosis. 

 
Brief Hospital Course:
Ms. ___ is a ___ yo woman with a hx of depression, GERD and 
migraines, presenting with an episode of facial numbness.

1. Facial numbness.  As this episode preceeded a headache, 
suspect likely due to a migraine equivalent, however episode 
could also be due to a TIA in the thalamus.  The patient had an 
MRI, which showed no signs of ischemia, and normal vasculature, 
making migraine equivalent a much more likely diagnosis.  
However, given the possibility of TIA, she has been started on a 
daily aspirin for future stroke prophylaxis.  Exam on discharge 
was notable for mild symmetric hyperreflexia in the lower 
extremities, but otherwise normal neurological exam, with no 
residual sensory deficits.
 
Medications on Admission:
NEXIUM 40 mg--1 capsule(s) by mouth once a day
PROZAC 20 mg--1 capsule(s) by mouth once a day

 
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily).  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Migraine 
 
Discharge Condition:
Mild symmetric hyperreflexia in the lower extremities, otherwise 
normal neurological exam.

 
Discharge Instructions:
You were admitted for left sided facial numbness.  You had an 
MRI which showed no signs of ischemia.  It is suspected that 
this was related to migraine headaches, but we recommend that 
you start taking a full dose of aspirin.

If you notice new numbness, weakness, worsening headaches, or 
other new concerning symptoms, please return to the nearest ED 
for further evaluation.
 
Followup Instructions:
___

{'Facial numbness': ['Other forms of migraine'], 'Mild diffuse dull HA': ['Other forms of migraine'], 'Achey': [], 'Diarrhea': [], 'Feeling achey': [], 'Abnormal reflex': ['Abnormal reflex']}