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white matter1 of 12 draggables.
wasting2 of 12 draggables.
pathology3 of 12 draggables.
somnolence4 of 12 draggables.
calcifications5 of 12 draggables.
coordination6 of 12 draggables.
hemorrhagic7 of 12 draggables.
balance8 of 12 draggables.
vertigo9 of 12 draggables.
electroencephalogram10 of 12 draggables.
mass11 of 12 draggables.
symptomatic12 of 12 draggables.
NEUROLOGICAL SYSTEM – FOLLOW UP REPORT
PATIENT NAME: Randy NORTON
AGE: 74
SEX: Male
DOB: October 14
DATE OF ASSESSMENT: January 18
ASSESSING PHYSICIAN: Martin Lewis, MD, Neurology
REASON FOR ASSESSMENT: Follow up assessment of cognitive changes and testing.
HISTORY: This 74-year-old patient was seen in consultation 10 days ago for assessment of cognitive changes. He underwent prescribed testing in the forms of cerebral MRI, (EEG) and blood was drawn for CBC and chem panel. The patient was seen by our local ENT for inner ear and testing. Test results showed normal hearing. No evidence of an inner ear that might have contributed to the or lack of balance and reported as part of the presenting symptoms.
TEST RESULTS: Cerebral MRI reveals a few T2 hyperintensities in the in the left temporal lobe. The right hemisphere shows some diffuse and some occipital wasting. There are multiple, small dark areas and a few areas indicative of ischemia.
EEG: This showed some depressive effect indicative of an encephalopathy. The patient did not sleep during the exam but did show some signs of . CBC and chem panels were normal.
IMPRESSIONS: This patient present with testing result that may be warning for Alzheimer wasting and also, some localized hemorrhagic events that have since stopped. This type of “leakage” is often not , and I do not feel that they are connected to his presenting complaints. I see no signs of tumor or formation nor infectious process.
On repeat verbal assessment, the patient reports he has not experienced any more of the spells. We will follow him closely in regards to the with a repeat MRI and perhaps a CT also in 3 months for results comparison to see whether the wasting has advanced or receded.
Thank you for asking me in on this most interesting case.
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Martin Lewis, MD, Neurology