Project 10.Instructor Solutions

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Valencia College *

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Apr 3, 2024

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PROJECT 10 - NEUROLOGY SOLUTIONS Task 10-1: Multiple Choice 1. A 2. C 3. B 4. D 5. A 6. C 7. A 8. D 9. C 10. A 11. B 12. A 13. C 14. D 15. B 16. C 17. C 18. A 19. C 20. B 1

Task 10-2: Medical Comprehension Activity 1. B 2. vomiting, seizures, and lethargy 3. B 4. B 5. B 6. A 7. D 8. C 9. D 10. B Task 10-3: Match Anatomical Terms 1. ___D ___ regulates automatic functions A. meninges 2. ___C ___ a gland that helps the body produce hormones it needs to respond to various situations. B. CSF 3. ___F ___ nerve cells C. pituitary 4. ___B ___ the watery substance that surrounds the brain. D. hypothalamus 5. ___A ___ protective connective tissue layers covering the brain. E. cerebrum 6. ___E ___ the uppermost and largest part of the brain F. neurons 7. ___J ___ the "thinking brain" G. ventricles 8. ___I ___ the protective covering of the neuron H. cerebellum 9. ___G ___ four small chambers connected to the spinal cord I. myelin sheath 10. __H ____ the "little brain" attached to the brainstem. J. cerebral cortex 2

Task 10-4: Proofreading Exercises PROOFREADING EXERCISE 1 - ANSWER (Changes indicated in BOLD) SUBJECTIVE: This 38-year-old female complains of 2 weeks of low back pain. She awoke one morning with this discomfort. She has done no new exercise and has not had any injuries. She is overweight and does not exercise on a regular basis. She cares for several children and does lift two who weigh between 34 and 40 pounds. Patient states the pain is dull and constant. It radiates to the left buttock and leg occasionally. This is described as a shooting pain which occurs with certain movements. She is otherwise in her usual state of health without complaints. OBJECTIVE: Musculoskeletal : Back has full range of motion forward, backward and sideward bending. No spinous process tenderness. There is paraspinal muscle tenderness with spasm noted in the low thoracic and upper lumbar area. No skin changes are noted. Lower extremities have 5/5 muscle strength grossly, 2/4 patellar reflex. Negative SLR . ASSESSMENT/PLAN: Low back pain with muscle spasm. Skelaxin 400 mg 2 p.o. q.6h. for 3 to 5 days, and Motrin 800 mg 1 p.o. q.8h. with food for 1 to 2 weeks, then p.r.n. No lifting greater than 10 pounds for 1 week. Recommend bed rest on a firm surface. Patient given exercise sheet to be done after acute phase . Followup on a p.r.n. basis . PROOFREADING EXERCISE 2 - ANSWER (Changes indicated in BOLD) HISTORY: Low back pain radiating into the right leg. INTERPRETATION: The patient has a normal appearance of the conus medullaris and the upper lumbar disk levels are well-maintained down to L2-L3. The L3-L4 area shows mild degenerative disk signal with only very slight narrowing. There is a small amount of posterior spurring at the L3-L4 interspace which combines with facet and ligamentum flavum hypertrophy to cause a mild degree of central spinal stenosis and lateral recess narrowing. The L4-L5 area shows moderate narrowing and more focal disk herniation that begins in the midline at the disk space and then just below the disk level extends eccentrically toward the right side. On the T1 axial images, we can see displacement and obscurity of the fat plane around the right L5 nerve root as it branches off. Although the sagittal images are not dramatic, I believe as they come over towards the right side that there is a disk herniation that is extending down over the lip of the L4-L5 interspace towards the right side. The L5-S1 area also shows moderate degenerative disk narrowing and a midline central disk protrusion causing approximately a 3 mm extradural defect on the thecal sac in the midline. This L5-S1 disk protrusion could be affecting the S1 or S2 roots as they begin to branch off, but I do not see any localization towards the right at this level. There is some degenerative facet disease at both L4-L5 and L5-S1, but no central spinal stenosis at these levels. The right L4-L5 foramen is compromised by the 3

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posterolateral disk herniation and facet change. IMPRESSION: Mild degenerative disk changes at L3-L4 and a moderate degree of central spinal stenosis at this level, some posterior spurring and facet and ligamentum flavum changes. Focal disk herniation at the L4-L5 level that is eccentric towards the right side and extends a short way below the L4-L5 disk to elevate and obscure nerve roots around the right L5 root as it branches off. There is a mild right L4-L5 foraminal narrowing from the posterolateral disk protrusion and facet change, but no definite compromise of the right L4 root. A central 3-mm disk protrusion at the L5-S1 level causing mild mass effect on the thecal sac and S1 roots as they branch off. Task 10-5: Cloze Exercises Cloze Exercise 1: Clinic Note (ESLIntMedBOS - #9003) SOLUTION: 1. singles 2. facial 3. gastroesophageal 4. rigidity 5. Peripheral 6. postherpetic neuralgia 7. Neurontin 8. EKG 9. sinus 10. antireflux Cloze Exercise 2: Clinic Note (FamMed1BOS - Report #31) SOLUTION: 4

1. pain 2. paresthesias 3. lupus 4. flare 5. Neurovascular 6. Brachial 7. rhomboid 8. subacromial 9. spasm 10. regimen Task 10-6: Transcription Exercises: Transcription Exercise 1: Brain Scan (AEAdvanced - Unit 6, Dictation 9) BRAIN SCAN HISTORY: Increasing disorientation and confusion times 1 month and with symptoms to the left side of the body. TECHNIQUE: Sagittal T1 and double-echo transaxial series as well as T1 unenhanced and gadolinium-enhanced sagittal transaxial and caudal series were obtained. FINDINGS: There is a cystic lesion without enhancement involving the anterior right temporal fossa which extends up into the anterior inferior frontal parietal region and Sylvian cistern consistent with moderate to large-sized arachnoid cyst. This is resulting in a moderate mass effect with resultant compression or atrophic changes of the gyri adjacent to the lesion in the anterior temporal lobe at the frontal parietal area. In the area below the insular cortex within the basal ganglia as well as the anterior right corona radiata, there are lacunar lesions which are presumed vascular insults from the mass effect. No abnormal enhancement of this area is observed. Normal vessel anatomy of the brain is otherwise observed. There is mild compression of the right lateral ventricle from the arachnoid cyst. No evidence of ventricular obstruction nor other abnormality of the brain was seen. The brainstem and upper cervical cord are normal. The structures of the face are otherwise 5

normal, as well. IMPRESSION: Large arachnoid cyst, anterior temporal fossa, extending up into the central parietal area and resulting in moderate focal mass effect without hydrocephalus. Second, old lacunar white matter infarcts are evident in the basal ganglia, as well, and are discussed above. Transcription Exercise 2: Letter (GenSurgBOS - Dictation #11) (Current date) James Wilson, MD 7500 Hanover Parkway Suite 101 Laurel, MD 21064 RE: Marjorie Smith Dear Dr. Wilson: Your patient, Marjorie Smith, was seen in the office approximately 3 weeks prior for persistent numbness and tingling in the right hand. The patient describes discomfort being more common at night or in the latter part of the day. She works with her hands and does much typing and filing and has been at her present job for approximately 20 years. Nerve conduction studies showed findings consistent with marked carpal tunnel syndrome in the right hand. The patient was taken to the hospital where, under regional block anesthesia on March 3, 1997, she underwent median nerve decompression. She tolerated the procedure well, and she was discharged the day of surgery. She was last seen in my office approximately one week ago, at which time she had good incisional healing, full function of her right hand, and all symptoms had disappeared. She has been instructed to return to full activity in approximately 2 weeks. She has been instructed to massage the scar in the palm with skin moisturizing cream at least 2 times per day. If I can be of any further assistance in the care of this patient, please do not hesitate to call. Sincerely, Transcription Exercise 3: Clinic Note (ESLIntMedBOS - #9027) CLINIC NOTE 6

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VISIT REASON: Concerns of low back pain and arthritis with polymyalgia rheumatica. The patient was placed on Prednisone at 5 mg daily which is helping her. She is also on Celebrex at 200 mg daily. PHYSICAL EXAMINATION: Examination reveals tenderness of the bilateral lumbar muscles. SLR is negative bilaterally. Reflexes are 2+ bilaterally in the lower extremities. Peripheral pulses are full bilaterally. There is no evidence of any muscle tenderness. IMPRESSION AND PLAN: 1. Possible worsening polymyalgia rheumatica. Will get a sed rate, TSH, CBC and CMP. Will continue on Celebrex for now and use Tylenol p.r.n. Depending on the sed rate, we will increase the dose of prednisone. 2. Hypertension, possibly secondary to the pain. Advised to check blood pressure at least twice daily and bring in records. 3. Arthritis. Currently on Celebrex and will continue on the same and will follow up. Transcription Exercise 4: CT Scan of the Brain (Rad1BOS - #3102) NAME OF TEST: Computerized tomography of the brain. TECHNIQUE: Axial CT images were obtained from the skull base through the vertex. Intravenous contrast was not given after auscultating the patient's lungs due to wheezing and the history of asthma. FINDINGS: There is no evidence of a ventriculomegaly. There are no focal parenchymal lesions. There are no extra-axial fluid collections. The cerebral convolutions are age appropriate. Bone windows demonstrate an intact cranium. IMPRESSION: No abnormalities seen. Transcription Exercise 5: Clinic Note (ESLIntMedBOS - #9031) CLINIC NOTE VISIT REASON: Post hospital visit for this young female who was admitted with history of chronic pain syndrome to the hospital recently. She also has a history of dysphagia and had an extensive workup done in the hospital which was inconclusive. The patient apparently was taken off of TPN [total parenteral nutrition] and placed on p.o. feeds which she is tolerating well currently. MEDICATIONS: She is currently on: 1. Lasix 20 mg daily p.r.n. 7

2. Potassium 10 mEq daily p.r.n. 3. Maxzide 75/25 mg daily p.r.n. 4. Citracal 400 mg p.o. b.i.d. 5. Premarin 1.25 mg daily. 6. Cortef 10 mg q.a.m. and 5 mg q.p.m. 7. Flexeril 10 mg p.o. b.i.d. p.r.n. 8. Soma 350 mg p.o. q.i.d. p.r.n. 9. Benadryl 50 mg IV at bedtime p.r.n. 10. Dilaudid 0.5 mg through the PCA pump at a basal rate and 0.5 mg p.r.n. at push. 11. Clonidine 0.1 mg patch p.r.n. 12. Valium 5 mg q.i.d., p.r.n. 13. Prevacid 30 mg p.o. b.i.d. 14. Actigall 600 mg at bedtime. 15. Compazine 5 to 10 mg p.o. p.r.n. 16. Phenergan 25 mg p.r.n. 17. Imodium p.r.n. 18. Combivent 2 puffs b.i.d. 19. Flovent 250 mcg 2 puffs b.i.d. 20. Verapamil 120 mg q.a.m. 21. Paxil 30 mg q.a.m. 22. Seroquel 100 mg q.a.m., 100 mg 5:00 p.m., and 300 mg at bedtime which was started recently by Dr. Kutzer. The patient has also been followed up by Dr. Kutzer. The patient has concerns about tachycardia as she has had several surgeries including pericardectomy. PHYSICAL EXAMINATION: GENERAL: The patient is a moderately-built, well-nourished female in no acute distress. VITAL SIGNS: BP 110/80. HEENT: There is no evidence of congestion or discharge. NECK: Supple. No JVD, carotid bruit or thyromegaly. CHEST: Chest shows air entry equal bilaterally. LUNGS: Clear to percussion and auscultation. CARDIOVASCULAR: Cardiovascular system show heart sounds to be normal. There was no murmur or gallop. ABDOMEN: The abdomen is soft and nontender. Bowel sounds are present in all quadrants. There is no rebound, guarding or rigidity. EXTREMITIES: Extremities show no evidence of edema. Peripheral pulses are full. LABORATORY DATA: An EKG was done today which showed sinus tachycardia without any ST-T-wave changes. IMPRESSION AND PLAN: This is a young female with a history of chronic pain syndrome currently on Dilaudid. The patient tried to wean off of Dilaudid recently which was unsuccessful. The patient also is currently being followed up by Dr. Kutzer, who has changed several different medications. The patient is also waiting for a pain management consult with Dr. Kaplan. Will continue on all the medications and p.r.n. medications for now. Currently she is not on any antibiotic. Will repeat a blood culture x2, will get a CBC, CMP, cholesterol profile and TSH, B12, folate level, and will follow up. The patient has also been followed by Dr. Larry Gordon. cc: Lawrence Gordon, MD 8

Task 10-7: Speech Recognition Exercises SRT Exercise 1: Clinic Note (ESLIntMedBOS - #9013) CLINIC NOTE VISIT REASON: Follow up of shingles. The patient had shingles of the anterior chest for which she was placed on Famvir for 5 days. She was told to go on Percocet which she has not taken as the pain was better controlled with Tylenol. PHYSICAL EXAMINATION: Vital signs are stable. Chaperoned by my nurse, the patient was examined. The shingles were in the healing stage with scab formation in the anterior to posterior chest wall. IMPRESSION AND PLAN: The patient is advised to take Percocet p.r.n. and will get a TSH, cholesterol profile, and CBC to look for evidence of anemia, and will follow up. SRT Exercise 2: X-ray Report (Rad1BOS - Report #3133) NAME OF TEST: Cervical Spine, 5 views. FINDINGS: There is narrowing of the disks at C4-5, C5-6, and C6-C7. Osteophytes are present anteriorly and posteriorly at all 3 levels. Osteophytes project into the neural foramina at C2-C3 through C6-C7 bilaterally. The vertebral body heights and alignment are maintained. IMPRESSION: Disk narrowing and osteophytes, as described. NAME OF TEST: Chest, PA and lateral. FINDINGS: There are no comparison films. There is no infiltrate, pleural effusion, or cardiomegaly. IMPRESSION: No active disease. NAME OF TEST: Right shoulder, 2 views. FINDINGS: No bone, joint, or soft tissue abnormality is seen. IMPRESSION: Negative examination. 9

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