Neurlogy Reevaluation1

NEUROLOGICAL REEVALUATION

HISTORY: This is a 33-year-old young lady with a known significant past medical history of orthostatic hypotension, seizure disorder, chronic lower back pain, and anxiety disorder who is seen today for a followup. The patient has been feeling slightly better over the last two weeks. The patient denies feeling depressed or sad. However, for the past last two days she has been experiencing some worsening of her lower back pain. The patient is currently taking Florinef 0.1 mg t.i.d. with persistent lightheadedness and dizziness when standing from a seated position and during activities of the day as well as walking. She is currently taking Keppra 250 mg b.i.d., Topamax 100 mg b.i.d., Effexor XR 75 mg two capsules q.h.s., and Vicodin as needed for pain.

PHYSICAL EXAMINATION: Physical examination today revealed a healthy?looking young lady in no apparent distress. The patient had reproducible dizziness when standing from a seated position. Blood pressure standing was 85/65 mmHg. The patient was able to heel-walk and tiptoe. The patient had normal cranial nerves examination II-XI. The patient had 5/5 in all muscle groups of the upper and lower extremities. The patient had moderate restrictions of lumbar spine mobility.

PLAN: The patient was advised to continue with the current dosage of her medication and increase only the Effexor to three tablets q.h.s. The patient will increase her fluid intake to a total of one gallon daily. The patient was started on Midodrine 5 mg t.i.d. The patient will be seen back for a followup in 3 weeks time. We will obtain liver function testing, CBC, and bicarbonate level. The patient will give me a call if she experiences any side effect on the medication.


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	NEUROLOGICAL REEVALUATION HISTORY: This is a 33-year-old young lady with a known significant past medical history of orthostatic hypotension, seizure disorder, chronic lower back pain, and anxiety disorder who is seen today for a followup. The patient has been feeling slightly better over the last two weeks. The patient denies feeling depressed or sad. However, for the past last two days she has been experiencing some worsening of her lower back pain. The patient is currently taking Florinef 0.1 mg t.i.d. with persistent lightheadedness and dizziness when standing from a seated position and during activities of the day as well as walking. She is currently taking Keppra 250 mg b.i.d., Topamax 100 mg b.i.d., Effexor XR 75 mg two capsules q.h.s., and Vicodin as needed for pain. PHYSICAL EXAMINATION: Physical examination today revealed a healthy?looking young lady in no apparent distress. The patient had reproducible dizziness when standing from a seated position. Blood pressure standing was 85/65 mmHg. The patient was able to heel-walk and tiptoe. The patient had normal cranial nerves examination II-XI. The patient had 5/5 in all muscle groups of the upper and lower extremities. The patient had moderate restrictions of lumbar spine mobility. PLAN: The patient was advised to continue with the current dosage of her medication and increase only the Effexor to three tablets q.h.s. The patient will increase her fluid intake to a total of one gallon daily. The patient was started on Midodrine 5 mg t.i.d. The patient will be seen back for a followup in 3 weeks time. We will obtain liver function testing, CBC, and bicarbonate level. The patient will give me a call if she experiences any side effect on the medication.

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