May-September 2022 Mom spends the summer going to PT, spending 5 days/week with Angel (5 hours daily, 25 hours per week). Basically stable and fine. Mom visits Wesley Des Moins, and decides to move there starting 10/1/22. I help her arrange movers and move out details. Carroll helps arranging move in/payment/forms for Wesley. Angel continues to help mom get medication renewed with Dr. Belman (psychiatrist). I recommend STRONGLY that mom finds a psychiatrist ASAP in Des Moins, so that she can continue to get medication. She has about a month extra supply, which will last until the end of October. I also recommended that she get an aide to help with bills, groceries, cleaning, and for anytime she walks long distances, especially if she is in a remote area.
_________________________________
9/2/22: Televisit with Dr. Belman refill meds. Full report and Psych discharge report here.
_________________________________
7/28/22: Mom visits Dr. Sabadia (neurologist). Assessment: This is 76-year-old woman with post-concussion syndrome, with significant anxiety and depression affecting her cognition. She now has daily migraines, likely due to her psych co morbidities and irregular sleep pattern. Full report here.
_________________________________
7/22/22 televisit with Dr. Belman refill meds. Full report here.
_________________________________
5/19/22 Mom complains of dizziness and pressure in her chest above her heart. Angel reaches out to me to ask if she should take her to Medrite Urgent Care and I tell her yes. At Medrite, a resident doctor suggests that she be taken by ambulance to Brooklyn Hospital so they can scan for heart attack. Angel rides with her in the ambulance to Brooklyn Hospital. I arrive shortly thereafter and help with registration. She has an EKG, blood work, and X-rays for her heart and lungs. All checks out okay, and the doctor tells us that she is “very healthy.” Mom attributes the pressure to stress and anxiety, and says that this situation was a “fumble”. She wants to get on a replacement for Buspar, which her GP (Itskowitz) had told her to stop taking in December, which she did. Her Psychiatrist (Belman) is out of town, and will be available on 5/23 to discuss a replacement for Buspar. Brooklyn Hospital discharge papers are here.
_________________________________
5/18/22 Mom has more severe headaches and paranoia, saying she is nervous someone is going to kill her. We have followed up again to try to get an appointment with her neurologist, Dr. Sabadia. She just needed to rest in doors all day today. I have urged her many times to get in-person appointments with her psychiatrist, Dr. Belman (next video appointment is scheduled for 6/3), and to find a talk therapist. I have sent numerous links to her with lists of therapists, and offered to help make an appointment for her.
_________________________________
4/18/22-5/16/22 Mom continues to work with Mamie Shaw twice weekly. Angel comes daily for usually 3 hours and walks with Mom every day - mom says this is excellent and very helpful. Mom volunteers on 4/28 at Fort Greene Park (close to her home) with gardening tasks. Angel assists. Mom enjoys this, but finds it difficult with balance issues, etc. She was scheduled again for 5/5 but cancels citing lack of sleep and headache. She decides not to continue to volunteer at the park.
_________________________________
3/17/22-4/17/22 Mom switches PT locations to another JAG ONE where Mamie Shaw works. This has been a better shift for her, despite the longer commute. Follow ups with Dr. Belman (psychiatrist) have happened, more medications filled. Mom is stable and looking into assisted living facilities in the NYC area.
_________________________________
3/8/22 - 3/17/22 Mom continues PT. Still not thrilled with therapists, although she feels Jeff has become great with neck massages. She will speak with JAG ONE about adjusting therapy sessions. She enjoys walking home. Angel has been very helpful and supportive, coming 3 days/week, roughly 11-12 hours per week.
_________________________________
3/3/22 Mom continues PT at the new location. She is not thrilled with the treatment as the therapists are overwhelmed. I recommended refreshing the discussion with the manager Jolynn to get the treatment she needs.
_________________________________
3/1/22 Angel continues to assist 3 days a week to the great delight and relief of Mom. Mom has a follow up video appointment with Dr. Wexler (neuropsychologist) after her neuropsychological test in December. The doctor recommended a psychologist and gave several referrals. She also recommended couples therapy with Carroll, more vestibular treatment, and a review of her medications. Notes from the meeting:
Patient: Janice Giteck
MRN: 15340262
Date of Birth: 6/27/1946
Referring Provider: Sabadia, Sakinah B, MD
Treating Diagnosis:
ICD-10-CM
ICD-9-CM
1.
Concussion with loss of consciousness of 30 minutes or less, sequela
S06.0X1S
907.0
2.
Memory dysfunction following head trauma
S09.90XA
780.93
R41.3
959.01
CPT: 96133 (3 units)
Treating Provider: Lucia Smith-Wexler, Ph.D., Licensed Psychologist
Primary Insurance: Payor: MEDICARE / Plan: MEDICARE PART A AND B / Product Type: Medicare /
Insurance ID#: @SUBNUM@
Secondary Insurance: N/A
=============================
Long Term Treatment Goal(s)
1) Complete written comprehensive neuropsychological report
Short Term Treatment Goal(s):
1) Complete feedback of neuropsychological evaluation results and recommendations
Patient’s Self-Stated Goal: See intake note
Goals have been discussed with patient and she is in agreement.
Janice Giteck was seen for 30 minutes of neuropsychological evaluation feedback. An additional 90 minutes were spent in test data interpretation, integration, and report writing.
Reviewed with patient that emergency contact will be notified if:
Patient should begin to experience medical or psychological crisis
Treatment is interrupted and patient cannot be contacted within 10 min.
Therapist confirmed that patient is at address: 150 Clermont Ave, 5k, Brooklyn, NY 11205
Patient's callback #: 206-852-5445
Emergency contact during telehealth visit: son 347-351-7326
Provider's location during telehealth visit: Remote Office
Patient's consent and agreement with the above plan was obtained for this telehealth visit.
Primary goals addressed in session were:
#1 above
The therapist's primary interventions were to:
1) Review evaluation results including areas of cognitive strength and weakness with patient
2) Discuss recommendations, including areas treatment will focus on addressing
3) Answer patient's questions regarding feedback and provide referrals
Changes in physical status or medication since last session: none reported
Patient's mood, mental status, and response to interventions:
Patient arrived independently and promplty to session. She appeared alert and oriented x3. Mood was depressed and anxious and affect was congruent. She was able to listen to feedback regarding results of evaluation. She acknowledged that areas of difficulty found on testing mirrored her experience. She expressed agreement with evaluation treatment recommendations, and was receptive of referrals to obtain long-term psychotherapy in the community and to follow-through with psychiatry consult.
Plan of Treatment: Given long-standing emotional difficulties impacting cognitive function, she is recommended for long-term psychological treatment in the community. See referrals and additional feedback below.
Based on the findings of this evaluation, the following recommendations are made:
Mrs. Giteck is experiencing long-standing significant emotional distress that is impacting her cognitive functioning and may be exacerbating physical symptoms. She is recommened to continue with her current psychotherapist and/or obtain a therapist with expertise in PTSD.
New York Presbyterian Psychiatry
For East Side of Manhattan or White Plains, call 212-821-0783.
For the West Side of Manhattan, call 646-774-9042.
The American Institute for Cognitive Therapy
212-308-2440
136 East 57th Street, Suite 1101, New York, NY 1101
Union Square Practice
212-3352100
138 W. 25th Street, 10th floor, New York, NY 10001
Based on the high elevations of mood symptoms, she would benefit from a psychiatric consultation.
Samuel Glazer, MD: 212-734-9859
Allah Iospa, MD: 646-383-7575
Philip Saltiel, MD: 212-223-2920
Lindsey Gurin, MD: 212-263-3210
Walk-in behavioral health pavilion at Metropolitan Hospital (no insurance or prior appointment needed): (212) 423-6262
Mrs. Giteck may benefit from couples and/or relationship therapy to address recent concerns regarding her marriage.
If headaches persist following significant improvement in mood, she may benefit from headache treatment at Rusk.
Complete another course of vestibular physical therapy.
Ms. Giteck should continue to follow-up with his referring physician and recommended therapies.
Engage in lifestyle behaviors that promote health and wellness: abstain from any substance use, eat balanced and nutritious meals, exercise as medically permitted/tolerable, and increase social involvement.
Obtain a re-evaluation if sudden changes in cognitive and/or emotional functioning occur.
Prognosis to Meet Goals: Good
_________________________________
2/22/22-2/24/22 While I’m away, home visits start with her new home aide, Angel. Mom reports that Angel is very helpful and attentive without being bossy. She is down to earth. The connection and help seems very positive. They walk home from PT on Tuesday, do shopping and walking on Wednesday, and on Thurs they take a Lyft home from PT because it is cold out.
_________________________________
2/18/22 I walked with mom casually today for about 1 1/2 miles. It was a cool but sunny day. She seemed to be leaning forward when walking - this seems to happen unpredictably. Then near the end of the walk she had another fall. I was right there with her walking and caught most of her weight before she hit the ground (she still landed on the ground, but not much impact). I think what is happening is that she seems okay waking slowly and casually, but then starts to lean forward as she is walking and then cannot recover her balance. Today I worked with her on taking a few steps, then stopping and taking a breath with a straight back and good posture, and then a few more steps, and then stopping again, etc. This might help her to stay focused and safe – like a slow and casual mediation. She really needs to keep her focus - her body is capable of walking, but her attention seems to have gaps and that is when she can get into trouble.
_________________________________
2/17/22 Mom continues low-key PT working on balance and focus. I pick her up and bring her home.
_________________________________
2/15/22 Mom cancels PT citing aches and fatigue.
_________________________________
2/15/22 We interview a home aide - Angel. She will come three times per week for 3 hours each day (starting the week of 2/21) to walk with mom back from PT and help her with light cleaning and home, and groceries, etc. Mom also wants her to help with bathing. We purchased a bath chair for my mom to use. Angel may also go to the gym in mom’s building to help with her some light exercise. It is my expectation/hope, that when mom walks anywhere for a distance she is aided.
_________________________________
2/10/22 On the walk home from PT, mom falls on the sidewalk, hits her head and jaw and right hand on the fall. She believes she blacked out for a few seconds. She is helped by two men who she describes as very kind. They call an ambulance. She calls me from the ambulance at 3:30, which is parked outside of Brooklyn Hospital. She describes the EMT’s as very kind and helpful. I arrive at Brooklyn Hospital shortly after 4pm and help with completing her intake. She is in a hospital bed awaiting attention from a doctor. She has a bruise on her chin on the right side, some mild cuts on her right hand, and complaining of general pain in her head. She is seen by two doctors who are very helpful - they order two cat scans for her shoulder and head, and an x-ray for her hand. All scans show no fractures or internal blending in her head. She seems a bit shaken, but no serious injury. We have been continuing to speak about more regular care - specifically an aide to walk with her. She believes she wasn’t paying attention to the sidewalk and tripped on some uneven pavement. She seems to be leaning forward often when walking, collapsing forward. Her cane may be set too low, so that she leans forward on it. I have urged her to work on her posture and walking with PT, and will continue to do so. She is discharged from the hospital and I take her home.
Click here for the discharge papers
_________________________________
2/10/22 Mom goes to PT and is pleased with the treatment - works with Jeff on a gentler touch on her neck. She feels positive overall about the treatment and is pleased to continue there.
_________________________________
2/8/22 Mom goes to PT and is alarmed by the distracting sounds, discussions crossing over, etc. Jeff is a little too firm in his massage treatment of Mom’s neck. She walks home.
_________________________________
2/3/22 Mom goes to PT and is pleased with the treatment from Cici and Jeff, continuing to work on balance and focus. She walks home.
_________________________________
2/1/22 Mom cancels PT today, citing lack of sleep.
_________________________________
1/28/22 Mom continues PT at JAG ONE, with CiCi and Jeff. They are very patient and helpful. They work on balance and focus, some walking exercises. We needed to get a new script for this - was acquired from Dr. Sabadia.
_________________________________
1/26/22 Mom has a video intake appointment with the Psych division of NYU Langone - Dr. Lindsay A Castro. She was very helpful and patient, and listened to my mom describe her issues and vision for treatment. A video visit was scheduled for March 8th with Lilian Belman, MD (psychiatrist).
_________________________________
1/6/22 Mom sees Dr. Sabadia (neurologist) for a follow up visit. Sabadia is pleased with the progress overall and the following up with the various doctors, and believes that the path forward from here will be with more PT focussing on strength and core building, and psych evaluation and treatment. She believes that there will be little to do on the neurological front at this point. She urges my mom to continue going to PT even though the vestibular treatment is not available at that location (because the vestibular treatment is not a priority at this point), and because she walks there and back. Mom needs more exercise. We have scheduled a video intake visit with the psych department at NYU Langone on 1/26/22, after which Mom will be hopefully be appointed to a psychiatrist to help medications going forward (and maybe talk therapy as well). We will do a follow up with Sabadia in May.
Notes on the visit:
Progress Notes - Clinical Notes
Sakinah B Sabadia, MD at 1/5/2022 4:30 PM
Sakinah Sabadia, MD
NYU Neurology Associates
222 East 41st Street, 9th Floor
New York, NY 10017
Phone: (212) 263-7744
Reason for Visit: concussion
HPI:
The patient is a 75 y.o. female who presents for follow-up for concussion.
Per her initial visit 10/6/21:
She was in a motor vehicle accident (as a pedestrian) in November 2017 in Seattle. She was walking across the street at a traffic circle, and an SUV hit her and ran over her. She lost consciousness for a few minutes. This happened right in front of her tai chi class. The driver got out of his car and fled the scene. Her classmates came out and helped her crawl out from under the car. She laid down for about 20 minutes, and then they took her to the ED. She had some scans done over 2 hours. She had a terrible headache which they gave her medications for. She does not recall there being any abnormalities on her scans. She was told she had a concussion and then was sent home. She stayed in bed for about 3 weeks. She continued to have terrible headaches, light and sound sensitivity, neck pain, nausea and loss of appetite.
Since then, her memory has been significantly affected. She has difficulty carrying on a conversation. She used to work a full-time professor but retired prior to her injury. She has been very depressed since her injury. She has a lot of trouble with her balance, and needs to use a cane or hold on to the wall. She did physical/vestibular therapy in Seattle which she thinks helps. She has had constant tinnitus, usually a high pitched squealing sound, mainly in the right ear. She had some hearing aids for the tinnitus (not hearing loss) but didn't find them helpful. She often gets lightheaded when she sits up or stands up too quickly. She was started on buspirone, lyrica, celebrex and effexor by doctors in Seattle (psychiatrist and PCP at Kaiser). These medications have helped her with her depression, anxiety and generalized body aches.
She was being taken care of by her partner for 3 years, then moved to NYC to spend time with her son and grandsons. She lives alone but a few blocks from her son. She often trips at home, and has fallen on the ground a few times. She doesn't always use her cane but feels she needs it.
Interval History:
In the interim, she had a brain MRI that showed moderate microvascular ischemic disease and a sinus infection. She had neuropsych testing with Dr. Smith-Wexler, notably her memory performance was impaired by distractibility. She established care with a PCP. Her buspirone was stopped.
She did about 15 sessions of vestibular and physical therapy and found it very helpful. She stopped her therapies about 1 month ago as the PT she was working with left, and she worries about COVID exposure. She used to walk home from her appointments which was 1.5 miles. She has not been exercising as much since she stopped the therapy and is not as motivated to go outside.
Her headaches have decreased in frequency. She often feels fatigued, and doesn't sleep well at night. She has an appointment with a psychiatrist in the next few weeks.
Past Medical History:
Past Medical History:
Diagnosis
Date•
Depression
effexore xr 150 Psych•
Excessive cerumen in ear canal, right
Hearing aid worn
12/25/2021
Hormone replacement therapy (HRT)
on half prempro qd
Memory changes
MRI 10/2021-Mod microvasc ischemic disease, ? rt maxillary sinus infection•
Memory dysfunction following head trauma
10/6/2021•
Nonintractable headache
12/25/2021
lyrica 25 bid and celebrex. f/u neuro•
Prediabetes
12/25/2021•
Routine adult health maintenance
Mammo colonosc DEXA tdap Pneumov flu Covid x1 (says got 3) shing•
Tinnitus
12/25/2021
Past Surgical History:
Past Surgical History:
Procedure
Laterality
Date•
CERVICAL DISCECTOMY
1998
after an MVA
Family History:
Family History
Problem
Relation
Age of Onset•
Frontotemporal Dementia
Father
Social History:
Social History
Tobacco Use•
Smoking status:
Former Smoker
Packs/day:
0.50
Years:
4.00
Pack years:
2.00•
Smokeless tobacco:
Never Used•
Tobacco comment: ex half ppd age 18-22
Substance Use Topics•
Alcohol use:
Not Currently•
Drug use:
Never
Allergies:
Allergies
Allergen
Reactions•
Penicillins
Other (See Comments)
Since child
Meds:
Current Outpatient Medications
Medication
Sig•
atorvastatin (LIPITOR) 10 mg tablet
Take 1 tablet by mouth daily.•
estrogen conjugated-medroxyPROGESTERone (PREMPRO) 0.625-2.5 mg per tablet
Take 1 tablet by mouth daily.•
pregabalin (LYRICA) 25 mg capsule
Take 1 capsule by mouth 2 (two) times a day. Max Daily Amount: 50 mg•
venlafaxine (EFFEXOR XR) 75 mg ER tablet
Take 1 tablet by mouth 2 (two) times a day.•
celecoxib (CELEBREX) 100 mg capsule
Take 1 capsule by mouth 2 (two) times a day.•
ondansetron (ZOFRAN ODT) 4 mg disintegrating tablet
Take 1 tablet by mouth every 12 hours as needed for Nausea.•
UNKNOWN TO PATIENT
Seriphos
Prempo 0.625mg/2.5 mg tab
ROS:
As per HPI
Physical Exam:
Vitals:
Vitals:
01/05/22 1636
BP:
110/87
Site:
Left Arm
Position:
Sitting
Pulse:
84
SpO2:
98%
Weight:
73.3 kg (161 lb 9.6 oz)
Height:
1.689 m (5' 6.5")
General: Well-appearing woman
Resp: Breathing comfortably on room air
CV: Warm, well-perfused.
Neurological Exam:
Mental Status: Awake, alert, oriented to person, place, and Wednesday, January 5th, 2022 (recalls that January 6th 2021 was the date of the Capitol riots). Provides clear detail of history of symptoms and interacts appropriately with examiner. Fluent speech, no dysarthria.
Cranial Nerves:
II: VF intact with finger counting.
III/IV/VI: EOMI without nystagmus
V: Facial sensation intact
VII: Facial musculature intact with forceful eyelid closure
XI: Shoulder shrug intact
Motor:
Bulk: normal
Tone: normal
Strength: 5/5 throughout the upper and lower extremities proximally and distally
Sensory:
Light touch: intact in the upper and lower extremities
Coordination: No dysmetria with finger to nose bilaterally.
Gait: Normal stance and stride. Arm swing normal and symmetric. Normal toe, heel and tandem walk.
Labs:
CBC, BMP, hepatic panel, B12, TSH, folate, syphilis, SPEP unremarkable
Hemoglobin A1c 5.8%
Imaging: MRI brain reviewed
Assessment: This is a 75-year-old woman with cognitive decline, imbalance, and depression following a head injury with LOC, likely due to post-concussion syndrome.
Plan:
- Continue PT, neuropsych and establish care with psychiatry
- Return in about 4 months (around 5/5/2022).
Sakinah Sabadia, MD
Clinical Assistant Professor
Department of Neurology
Total time spent on the day of the visit, including pre-visit and post-visit time, was 28 minutes.
_________________________________
12/21/21 Mom sees Dr. Ina Itzkovitz (primary care physician). Itzkovitz recommends mom stops taking busPIRone (15mg tablets - BUSPAR), and reduce venlafaxine (EFFEXOR XR). busPIRone can cause tinnitus. Itzkovitz also refers to an Ophthalmologist to screen for glaucoma, and an ENT for tinnitus. As of 1/6/22 these appointments have not been made. Itzkovitz also orders a mammogram, XR Dexa bone density spine and hips screening, and a cologuard self-kit (colonoscopy).
Notes on this appointment:
H&P - Clinical Notes
Ina S Itzkovitz, MD at 12/21/2021 11:20 AM
Janice Giteck is a 75 y.o. female Here for physical
Pt has tiinutus but on buspar which can cause that . Also dizzines and buspar Can cause that
Has hearing aids though
Depressed on effexor xr 150 ( takes 2 of 75) and will seeing psych. Feels related to accident 2017
MRI Brain 10/18/21 Mod microv ischem disease Never told of high chol Possible rt max sinusitis. Now nasal passages open and no sinus pain
On prempro Very overdue for mamm
Years since colonosc. Declining but would do cologuard. DEXA
Needs flu and pneumon Got covid x 3 Needs tdap and shing
All Pmedhx as a ve Prediabetes a1fc 5,8 PSurghx Vag delivery , cerv disc SH ex cigs half18-22 etoh None Has live in girlfriend For 40 yrs Occup retired Composer, College professor ( UC Berkely, cornis) Pets at home chicken ROS Mother died 88 MI Father died 86 was in fire 2 sisterswell
ROS: see HPI, otherwise negative
Current Outpatient Medications:
• estrogen conjugated-medroxyPROGESTERone (PREMPRO) 0.625-2.5 mg per tablet, Take 1 tablet by mouth daily., Disp: 30 tablet, Rfl: 6
• pregabalin (LYRICA) 25 mg capsule, Take 1 capsule by mouth 2 (two) times a day. Max Daily Amount: 50 mg, Disp: 60 capsule, Rfl: 3
• venlafaxine (EFFEXOR XR) 75 mg ER tablet, Take 1 tablet by mouth 2 (two) times a day., Disp: 60 tablet, Rfl: 6
• celecoxib (CELEBREX) 100 mg capsule, Take 1 capsule by mouth 2 (two) times a day., Disp: 60 capsule, Rfl: 1
• ondansetron (ZOFRAN ODT) 4 mg disintegrating tablet, Take 1 tablet by mouth every 12 hours as needed for Nausea., Disp: 20 tablet, Rfl: 0
• UNKNOWN TO PATIENT, Seriphos Prempo 0.625mg/2.5 mg tab, Disp: , Rfl:
Allergies
Allergen
Reactions•
Penicillins
Other (See Comments)
Since child
Past Medical History:
Diagnosis
Date•
Depression
effexore xr 150 Psych
Excessive cerumen in ear canal, right
Hearing aid worn
12/25/2021
Hormone replacement therapy (HRT)
on half prempro qd
Memory changes
MRI 10/2021-Mod microvasc ischemic disease, ? rt maxillary sinus infection
Memory dysfunction following head trauma
10/6/2021
Nonintractable headache
12/25/2021
lyrica 25 bid and celebrex. f/u neuro
•
Prediabetes
12/25/2021
Routine adult health maintenance
Mammo colonosc DEXA tdap Pneumov flu Covid x1 (says got 3) shing
Tinnitus
12/25/2021
Past Surgical History:
Procedure
Laterality
Date
CERVICAL DISCECTOMY
1998
after an MVA
Social History
Socioeconomic History
Marital status:
Significant Other
Spouse name:
Not on file
•
Number of children:
1
Years of education:
Not on file
Highest education level:
Not on file
Occupational History
•
Occupation:
retired composer, college professor
Tobacco Use•
Smoking status:
Former Smoker
Packs/day:
0.50
Years:
4.00
Pack years:
2.00•
Smokeless tobacco:
Never Used•
Tobacco comment: ex half ppd age 18-22
Substance and Sexual Activity•
Alcohol use:
Not Currently•
Drug use:
Never•
Sexual activity:
Yes
Partners:
Female
Comment: live in girlfriend 40 yrs
Other Topics
Concern•
Not on file
Social History Narrative
Female live in girlfriend, 1 son -lives in NY and visiting son and grandchildren for awile Occup Retired composer,(UC Berkeley, Cornish) Pets at home- chickens
Social Determinants of Health
Financial Resource Strain: •
Difficulty of Paying Living Expenses: Not on file
Food Insecurity: •
Worried About Running Out of Food in the Last Year: Not on file•
Ran Out of Food in the Last Year: Not on file
Transportation Needs: •
Lack of Transportation (Medical): Not on file•
Lack of Transportation (Non-Medical): Not on file
Physical Activity: •
Days of Exercise per Week: Not on file•
Minutes of Exercise per Session: Not on file
Stress: •
Feeling of Stress : Not on file
Social Connections: •
Frequency of Communication with Friends and Family: Not on file•
Frequency of Social Gatherings with Friends and Family: Not on file•
Attends Religious Services: Not on file•
Active Member of Clubs or Organizations: Not on file•
Attends Club or Organization Meetings: Not on file•
Marital Status: Not on file
Intimate Partner Violence: •
Fear of Current or Ex-Partner: Not on file•
Emotionally Abused: Not on file•
Physically Abused: Not on file•
Sexually Abused: Not on file
Housing Stability: •
Unable to Pay for Housing in the Last Year: Not on file•
Number of Places Lived in the Last Year: Not on file•
Unstable Housing in the Last Year: Not on file
Family History
Problem
Relation
Age of Onset•
Frontotemporal Dementia
Father
Vitals:
12/21/21 1121
BP:
130/82
Site:
Left Arm
Position:
Sitting
Pulse:
82
Temp:
36.5 °C (97.7 °F)
TempSrc:
Temporal
SpO2:
98%
Weight:
72.3 kg (159 lb 6.4 oz)
Height:
1.689 m (5' 6.5")
Physical Exam:
General Appearance: cooperative, no acute distress,
HEENT: PERRL, conjunctiva clear, EOM's intact, non injected pharynx, no exudate, TM normal Lt Obscured by wax on rt
Neck: Supple, no adenopathy, thyroid: not enlarged, no carotid bruit or JVD
Back: Symmetric, no cva tenderness, no soft tissue tenderness
Breasts: no masses, no axillary lymphadenopathy
Lungs: Clear to auscultation and percussion bilaterally,no adventitious breath sounds, normal expiratory phase
Heart: Regular rate and rhythm, S1, S2 normal, no murmur, rub or gallop
Abdomen: Soft, non-tender, bowel sounds active, no hepatosplenomegaly
Extremities: no clubbing, cyanosis or edema, no joint swelling
Skin: Skin color, texture normal, no rashes
Neurologic: Alert and oriented X 3, Gait-normal,cranial nerves intact, sensory and motor normal
I+P:
1 routine Labs
2 Memory deficit Pt excellent historian MRI brain mod microvasc ischemc change. Check chol Pt told due to concussion 2017
3 headache On lyrica 25 bid and celebrex Seeing neuro
5 tinnitus rt Stop buspar, can cause this but also has hearing
6 hearing aids
7 excess cerumen rt ENT
8 prediabetes 5.8
9 Depression on effexor xr 150 Psych
10 HRT Now on half a prempro No mammo for year but needs
11 screen for breast mammo mammo
12 Screen for colon cancer cologuard
13 Screen for osteoporosis DEXA
14 need for flu shot left
15 needs for pneumov Left without
16 elev blood pressure
Labs mammo cologuard DEXA EKG 60 NSR wnl
ENT and ophthalm F/u neuro
Covid x 3 At pharm tdap and shingrix Return for pneumov, fll
_________________________________
12/14/21 Neurospychological Intake exam lasting approximately 5 hours with Dr. Lucia Smith Wexler. Notes:
Progress Notes - Clinical Notes
Lucia Smith-Wexler, PhD at 12/14/2021 9:15 AM
NEUROPSYCHOLOGICAL INTAKE
Date: 12/14/2021
Patient: Janice Giteck
MRN: 15340262
Date of Birth: 6/27/1946
Primary Diagnosis:
ICD-10-CM
ICD-9-CM
1.
Concussion with loss of consciousness of 30 minutes or less, sequela
S06.0X1S
907.0
AMB REFERRAL TO PSYCHOLOGY
AMB REFERRAL TO PSYCHOLOGY
2.
Memory dysfunction following head trauma
S09.90XA
780.93
AMB REFERRAL TO PSYCHOLOGY
R41.3
959.01
AMB REFERRAL TO PSYCHOLOGY
Date of Onset: November 2017
Referring Physician: Sabadia, Sakinah B, MD
Lic. Psych: Lucia Smith-Wexler, PhD
CPT: 96116 (1 unit); 96136 (1 unit), 96137 (7 units), 96132 (1 unit), 96133 (1 unit)
Primary Insurance: N/A
Insurance ID#: N/A
Secondary Insurance: N/A
=======================================
Reason for Referral: Mrs. Janice Giteck is a 75-year-old, right-handed, white, female who was referred for a neuropsychological evaluation by Sakinah Sabadia, MD secondary to a concussion with persistent post-concussion symptoms. The purpose of this evaluation was to assess Mr/s. current cognitive and emotional functioning, and to inform recommendations.
Documents Reviewed: Electronic medical record (EMR)
Interpreter Present: No, patient's preferred language is English. @LANG@
Culture & Religious Practices: These practices do not affect services
BACKGROUND INFORMATION
Background information was obtained from an interview with Ms. Janice Giteck and a review of available EMR.
History of Presenting Problem: According to electronic medical record, "She was in a motor vehicle accident (as a pedestrian) in November 2017 in Seattle. She was walking across the street at a traffic circle, and an SUV hit her and ran over her. She lost consciousness for a few minutes. This happened right in front of her tai chi class. The driver got out of his car and fled the scene. Her classmates came out and helped her crawl out from under the car. She laid down for about 20 minutes, and then they took her to the ED. She had some scans done over 2 hours. She had a terrible headache which they gave her medications for. She does not recall there being any abnormalities on her scans. She was told she had a concussion and then was sent home. She stayed in bed for about 3 weeks. She continued to have terrible headaches, light and sound sensitivity, neck pain, nausea and loss of appetite.
Since then, her memory has been significantly affected. She has difficulty carrying on a conversation. She used to work a full-time professor but retired prior to her injury. She has been very depressed since her injury. She has a lot of trouble with her balance, and needs to use a cane or hold on to the wall. She did physical/vestibular therapy in Seattle which she thinks helps. She has had constant tinnitus, usually a high pitched squealing sound, mainly in the right ear. She had some hearing aids for the tinnitus (not hearing loss) but didn't find them helpful. She often gets lightheaded when she sits up or stands up too quickly. She was started on buspirone, lyrica, celebrex and effexor by doctors in Seattle (psychiatrist and PCP at Kaiser). These medications have helped her with her depression, anxiety and generalized body aches.
She was being taken care of by her partner for 3 years, then moved to NYC to spend time with her son and grandsons. She lives alone but a few blocks from her son. She often trips at home, and has fallen on the ground a few times. She doesn't always use her cane but feels she needs it.
Was there loss of consciousness? Yes, Over one minute
Was there amnesia for the event? yes
If yes, for how long? unclear"
Current Symptoms:
· Cognitive Symptoms
o Concentration and Awareness
· "Not good"
· Trouble focusing on what she read
o Memory
· "Memory loss, horrible"
· Trouble recalling conversations
o Speed of Information Processing
§ Notices thinking is slower
o Speech & Language
· Notices she's very quite now
o Problem Solving
· Not thinking clearly
o Instrumental Activities of Daily Living and Activities of Daily Living
§ Stopped driving due to accident
§ Finances: independent/dependent
§ Grocery shopping: independent/dependent
§ Cooking: independent/dependent
§ Cleaning: independent/dependent
§ Getting to places: independent/dependent
§ Using a phone: independent/dependent
§ Grooming: independent/dependent
§ Feeding: independent/dependent
· Emotional & Interpersonal Functioning
· PTSD
· Anxiety (historical)
· Depression (historical)
· Reduced intimacy
· Social Withdrawal
· In psychotherapy for many years
· Living alone currently, but close to son
· Is looking for a psychiatrist
· Physical Symptoms
· Headaches ("often")
· Sensitivity to noise/light
· Vision: Eye glasses to see close
· Auditory: Tinnitus "all the time" that is like "buzzing"
· Sleep: trouble sleeping through the night, sometimes can't sleep or only for 3 hours,” averages 5-6 hours/night
· Appetite: “too much"
Prior Functional Level: Age-appropriate level of personal, social, and occupational functioning prior to this event.
Current Medications Relevant to Services (Reported by Patient/Not to be considered a full list of medications):
Current Outpatient Medications
Medication
Sig
•
ondansetron (ZOFRAN ODT) 4 mg disintegrating tablet
Take 1 tablet by mouth every 12 hours as needed for Nausea.
•
busPIRone (BUSPAR) 15 mg tablet
Take 15 mg by mouth 3 (three) times daily.
•
celecoxib (CELEBREX) 100 mg capsule
Take 100 mg by mouth 2 (two) times a day.
•
pregabalin (LYRICA) 25 mg capsule
Take 25 mg by mouth 2 (two) times a day.
•
UNKNOWN TO PATIENT
Seriphos
Prempo 0.625mg/2.5 mg tab
•
venlafaxine (EFFEXOR XR) 75 mg ER tablet
Take 75 mg by mouth daily.
Social History:
· Born/Raised: Brooklyn, NY/Raised by both parents (father: store-owner, mother:writer and stenography teacher).
· Primary language: English
· Early Development: Unremarkable/No history of learning disabilities
· Highest Education: 21 years of education, 2 masters in music composition and clinical psychology, paris conservatory 1 year for composing music
· Vocation/Industry: Professional mucisian, university professor for over 30 years, composer of music, years/retired
· Marital/Family: Divorced from a prior heterosexual marriage, Recently separated from partner for 40 years that she is in separation/1 son
· Religion: Buddhist
· Evidence of Abuse/Neglect: No signs observed by therapist or reported/Past history of strict childhood and family conflict
· Substance Use/Abuse:
o Denied current and prior use of tobacco, alcohol, and/or illicit drug use
Relevant Medical/Surgical History and Allergies:
· has no past medical history on file.
· Past Surgical History:
Procedure
Laterality
Date
•
CERVICAL DISCECTOMY
1998
after an MVA
· Neck surgery prior to accident -3 discs removed
Allergies reviewed by therapist in chart.
Relevant Family Psychiatric/Medical History: Dementia (father), Myocardial infarction (mother), neuroticism (mother)
Comorbidities: Pre-existing mood disorder: see above
Previous Trauma: see above
Social Support to assist with condition from: son and partner to a lesser extent
Pain Assessment: Denied current pain.
Falls-Risk Assessment:
-Reported falling out of bed a couple times onto her back due to carelessness. She was trying to reach for something.
Patient's Self-stated Rehabilitation Goal: I need an emotional support, and a mental support in making the right choices
Behavioral Observations:
Appearance:
age appropriate and casually dressed
Behavior:
Restless & fidgety
Speech:
Within normal limts
Mood:
anxious and depressed
Affect:
blunted and constricted
Thought Process:
tangential
Thought Content:
Denied all the following: delusions, hallucinations, obsessions, homicidal & suicidal ideation, plan and intent
Orientation:
person, place and time/date
Cognition:
grossly intact
Insight:
fair
Judgment:
fair (not formally assessed)
Motor:
Sometimes uses a cane to walk outside
Suicide Risk:
Denied prior and current suicidal ideation, plan and intent
Ms. Janice Giteck arrived aver 10 minutes late and alone to the testing session. During the evaluation, rapport was easily established. She recounted her history in a detailed manner. She easily transitioned to the testing format, and followed all test directions with repetition of direction required at times. She commented on her difficulties during testing. She appeared to be surprised when she experienced some difficulty on a nonverbal task. She became distracted during a memory task, commenting during recall trials about her relationship concerns and stressors. She required some clinician redirection to focus on the memory task. She demonstrated appropriate frustration tolerance during most of the testing, but expressed becoming angry when challenged and required clinician support to continue a task. Overall, Ms. Janice Giteck tolerated testing well, with good effort. However, distractibility likely impacted memory performance As such, results on portions of this evaluation may not be an adequate estimate of her current abilities, and should be interpreted with caution.
Patient was seen for 180 minutes of face-to-face contact. An additional 90 minutes were spent in records review, scoring, and report writing for a total CPT units of: 96116 (1 unit); 96136 (1 unit), 96137 (7 units), 96132 (1 unit), 96133 (1 unit). CPT units for today's session will be billed at the feedback session. Today was billed NC Assessment.
Session Goal(s):
1) Explain role of neuropsychologist in evaluation/treatment of medical conditions.
2) Perform intake interview.
3) Initiate Neuropsychological Evaluation.
4) Make appointment for feedback and discussion of results/recommendations.
Primary goals addressed in session were:
All of the above.
The therapist's primary interventions were to:
Interview patient and administer tests of symptom status, effort, attention/concentration, memory, verbal and visuospatial skills, executive functioning, and mood/behavior.
Barrier(s) that may impede participation: None
Assessment of Patient's Ability to Participate in Rehabilitation
Assessment Completed
____Yes
__X___Not able to complete at this time
Person responding to questions regarding patient's ability to participate:
__X__Patient
___Spouse
___Parents
___Domestic Partner
__Caregiver
___Other:
Barriers/Limitations affecting patient's ability to participate:
_X__None
___Activity
___Cognitive Impairment
___Hearing Impairment
___Financial
___Language
___Visual Impairment
___Speech Impairment
___Emotional
___Pain
___Physical Disability
___Cultural/Religious
___Other:
Patient's Learning-Style Preferences:
___ Auditory
___ Written
__X__ Both Auditory and Written
___Other:
Patient expressed readiness to learn and participate:
_X___ Yes
____ No
Plan: The plan is to meet with patient to discuss evaluation results and recommendations full written report will follow completion of assessment.
_________________________________
12/16/21 Dr. Sabadia (neurologist) fills the prescriptions as a one time courtesy for Mom’s medications, as she has not been able to find a Primary Care Physician or Psychiatrist to help with this.
_________________________________
Dec 2021 - Dr. Mamie Shah has left Jag One Physical Therapy, and is training another therapist in vestibular treatment. Omicron is on the rise. Mom did not continue PT during December as she feels unsafe in the small PT room, and sad that Dr. Shah has left (even though the vestibular treatment is no longer necessary)
_________________________________
11/30/21 Mom continues PT.
_________________________________
11/26/21 PT cancelled - Dr. Shah out of the office for Thanksgiving.
_________________________________
11/23/21 Mom cancels PT for lack of sleep
_________________________________
11/19/21 Mom continues PT with Dr. Shah and an assistant - working on balance and stretching exercises.
_________________________________
11/16/21 Mom continues PT with Dr. Shah and an assistant - working on balance and stretching exercises.
_________________________________
11/12/21 Mom cancels PT for lack of sleep, and imbalance caused by deep tissue massage on previous session.
_________________________________
11/9/21 Mom continues PT with Dr. Shah and an assistant - working on balance and stretching exercises. Deep tissue massage on neck.
_________________________________
11/5/21 Mom cancels PT with Dr. Shah to continue to recover from sinusitis, and a UTI that occurred from taking antibiotics. She is taking probiotics and cranberry UTI pills.
_________________________________
11/2/21 Mom continues PT with Dr. Shah. She massaged Mom’s neck, and her assistants helped with stretches. Spoke with the doctor about balance, which has been better since the treatments. Several follow up appointments were scheduled. Mom walked around for several hours after, and took a bus home.
_________________________________
10/26/21 Mom continues vestibular PT today with Dr. Shah, and describes it as intense and beneficial - jostling the “crystals” around in her inner ear. She was able to walk a straight line through the PT office on a tape line on the ground confidently. The treatment caused nausea as expected, and she is taking the anti-nausea medication prescribed by Dr. Sabadia. Mom walked home from the PT office (about 1 1/2 miles).
I played phone tag today with Rusk Rehabilitation to schedule Neuropsychological testing.
_________________________________
10/22/21 Mom cancel’s PT appointment today due to symptoms and nausea from antibiotics and acute sinus infection. Will continue PT appointments next week.
I have been in contact with the Rusk Rehabilitation at NYU to schedule the Neuropsychological testing.
_________________________________
10/20/21 Dr. Sabadia notices the acute sinus infection noted on the MRI, and suggests that my mom see a GP to get a prescriptions for anti-biotics, if needed. We take my mom to MedRite Urgent Care in Brooklyn to meet with a doctor, who prescribes Doxycycline for 7 days. My mom starts Doxy, which she says makes her nauseated (this is an expected side effect).
_________________________________
10/19/21 Mom goes to JAG One Physical Therapy in Brooklyn, we visit with Dr. Mamie Shah. She begins vestibular therapy, which has an immediate positive effect on my mom’s ability to follow objects successfully with her eyes. As expected, the therapy causes residual dizziness and nausea, which is expected to last a day or two after each time. Mom reaches out to Dr. Sabadia to prescribe anti-nasuea and anti-dizziness medication, as suggested by Dr. Shah. Dr. Shaw scheduled follow up appointments on 10/22/21, 10/26/21, and 10/28/21 for continuation of vestibular therapy.
_________________________________
10/14/21 Mom goes to JAG One Physical Therapy in Brooklyn, we visit with Dr. Shah. She establishes the vestibular issues my mom is having, and proposes follow up appointments to work on these. She describes that “crystals” are misaligned in my mom’s inner vestibular system. She believes she can work on this and have a positive effect quickly.
_________________________________
10/18/21 MRI performed at NYU. Results here:
Study Result
Impression
IMPRESSION:
Moderate microvascular ischemic disease.
Concern for acute right maxillary sinus bacterial infection. Correlate clinically.
Narrative
CLINICAL INDICATION: Head injury November 2017 with loss of consciousness. Since then has had memory difficulties and daily headaches.
TECHNIQUE: Multi-planar multi-sequential MR imaging of the brain was performed without intravenous contrast.
COMPARISON: None available
FINDINGS:
No acute infarction, intracranial hemorrhage or mass. Moderately extensive patchy and confluent white matter disease 2/FLAIR hyperintensities are noted without mass effect. Additional signal abnormalities are noted in the pons. These findings are consistent with moderate microvascular ischemic disease.
There is mild to moderate cerebral volume loss.No extra-axial fluid collections. The skull base flow voids are present.
The right maxillary sinus is partially opacified by mucosal disease and central T2-hypointense foamy debris that appears to form a fluid level and which demonstrates restricted diffusion. These findings are concerning for acute bacterial sinusitis. Correlate clinically
The visualized intraorbital contents are normal. The mastoid air cells are clear. The visualized osseous structures, soft tissues and partially visualized parotid glands appear normal.
Electronic Signature: I personally reviewed the images and agree with this report. Final Report: Dictated by and Signed by Attending John Loh MD 10/19/2021 12:45 PM
_________________________________
10/6/21 Dr. Sakinah B. Sabadia seen at NYU Langone Neurology. Dr. Sabadia was very patient and helpful, listened to my mom describe the issues she has been experiencing since the car accident in Nov 2017. She recommended blood work (see results below - results were normal). She did many reflex and cognitive testes. Dr. Sabadia recommended physical therapy for the vestibular issues. She also recommended a Neuropsychological test through NYU. This test is a series of tests that last 3 days. It is very hard to schedule as there are very few doctors doing this test during covid. Dr. Sabadia also scheduled an MRI on 10/18/21
Summary of visit on 10/6/21:
Sakinah B Sabadia, MD at 10/6/2021 4:00 PM
Sakinah Sabadia, MD
NYU Neurology Associates
222 East 41st Street, 9th Floor
New York, NY 10017
Phone: (212) 263-7744
Reason for Visit: concussion
HPI:
The patient is a 75 y.o. female who presents with persistent symptoms after a head injury
Details are as follows:
Date of injury: November 2017
Approximate time of injury: 6PM
History/mechanism of injury:
She is accompanied by her son Max.
She was in a motor vehicle accident (as a pedestrian) in November 2017 in Seattle. She was walking across the street at a traffic circle, and an SUV hit her and ran over her. She lost consciousness for a few minutes. This happened right in front of her tai chi class. The driver got out of his car and fled the scene. Her classmates came out and helped her crawl out from under the car. She laid down for about 20 minutes, and then they took her to the ED. She had some scans done over 2 hours. She had a terrible headache which they gave her medications for. She does not recall there being any abnormalities on her scans. She was told she had a concussion and then was sent home. She stayed in bed for about 3 weeks. She continued to have terrible headaches, light and sound sensitivity, neck pain, nausea and loss of appetite.
Since then, her memory has been significantly affected. She has difficulty carrying on a conversation. She used to work a full-time professor but retired prior to her injury. She has been very depressed since her injury. She has a lot of trouble with her balance, and needs to use a cane or hold on to the wall. She did physical/vestibular therapy in Seattle which she thinks helps. She has had constant tinnitus, usually a high pitched squealing sound, mainly in the right ear. She had some hearing aids for the tinnitus (not hearing loss) but didn't find them helpful. She often gets lightheaded when she sits up or stands up too quickly. She was started on buspirone, lyrica, celebrex and effexor by doctors in Seattle (psychiatrist and PCP at Kaiser). These medications have helped her with her depression, anxiety and generalized body aches.
She was being taken care of by her partner for 3 years, then moved to NYC to spend time with her son and grandsons. She lives alone but a few blocks from her son. She often trips at home, and has fallen on the ground a few times. She doesn't always use her cane but feels she needs it.
Was there loss of consciousness? Yes, Over one minute
Was there amnesia for the event? yes
If yes, for how long? unclear
Current symptoms:
Headache: Yes, but improved, still occurring every day. Lasting about 1-2 hours. She takes Tylenol which helps.
Neck pain / MSK: yes
Vestibular / Autonomic: lightheaded with standing. tinnitus
Visual: light sensitivity
Sleep: sleeps often throughout the day
Cognitive (briefly): very slowed
Affective: depressed
Functional activity levels:
Work: retired
Physical activity: goes on walks, feels worse
Is there a history of prior concussion(s)? yes
How many previous concussions? 2
Is there a personal or family history of headaches? No
Is there a personal or family history of psychiatric problems or substance abuse? No
Concussion Symptom/Severity Evaluation:
Current symptoms are as follows (0-6 scale):
Headache: 5.
“Pressure in head:” 6.
Neck pain: 4.
Nausea or vomiting: 4.
Dizziness: 4.
Blurred vision: 0.
Balance problems: 5.
Sensitivity to light: 4.
Sensitivity to noise: 5.
Feeling slowed down: 6.
Feeling like “in a fog:” 6.
“Don’t feel right:” 6.
Difficulty concentrating: 6.
Difficulty remembering: 6.
Fatigue or low energy: 6.
Confusion: 5.
Drowsiness: 6.
More emotional: 4.
Irritability: 5.
Sadness: 6.
Nervous or anxious: 6.
Trouble falling asleep: 2.
Total number of symptoms: 21/22.
Symptom severity score: 107/132.
Do the symptoms get worse with physical activity? No.
Do the symptoms get worse with mental activity? No.
If 100% is totally normal what % of normal do you feel? 20%
Standardized Assessment of Concussion (SAC):
Orientation
What month is it? 1.
What is the date today? 1.
What is the day of the week? 1.
What year is it? 1.
What time is it right now (within one hour)? 1.
Orientation score: 5/5.
Immediate memory (5 Word List)
Baby monkey perfume sunset iron
First time: 5.
Second time: 5.
Third time: 5.
Immediate memory score: 15/15.
Concentration (reverse digit span)
4-1-5 Score: 1
4-9-6-8 Score: 1
6-1-8-4-3 Score: 1
7-2-4-8-5-6 Score: 0
Months in reverse order Score 1
(Dec-Nov-Oct-Sep-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan)
Concentration score: 4/5.
Delayed recall score: 0/5.
SAC total score: 24/30.
Modified Balance Error Scoring System (MBESS):
Which leg is dominant? left
20 second double leg firm ground: 10
20 second single leg firm ground (non-dominant foot): 8 (falls over and takes seconds to reset)
20 second tandem firm ground (non-dominant foot at back): 10
MBESS Total Score: 28/30.
MULES: 128 seconds, 3 errors (calls fish a blue jay, camel/llama a giraffe and shark a fish)
Neurological Screen
Can the patient read aloud and follow instructions without difficulty? yes
Does the patient have a full range of pain free passive cervical spine movement? yes
Without moving their head or neck , can the patient look side-to-side and up-and-down without double vision?yes
Can the patient performed the finger nose finger test normally?yes
Can the patient perform tandem gait normally? no
----------
Past Medical History:
History reviewed. No pertinent past medical history.
Past Surgical History:
Past Surgical History:
Procedure
Laterality
Date
•CERVICAL DISCECTOMY
1998
after an MVA
Family History:
Family History
Problem
Relation
Age of Onset
•Frontotemporal Dementia
Father
Social History:
Social History
Tobacco Use
•Smoking status:
Never Smoker
•Smokeless tobacco:
Never Used
Substance Use Topics
•Alcohol use:
Not Currently
•Drug use:
Never
Allergies:
Allergies
Allergen
Reactions
•Penicillins
Other (See Comments)
Since child
Meds:
Current Outpatient Medications
Medication Sig
•busPIRone (BUSPAR) 15 mg tablet
Take 15 mg by mouth 3 (three) times daily.
•celecoxib (CELEBREX) 100 mg capsule
Take 100 mg by mouth 2 (two) times a day.
•pregabalin (LYRICA) 25 mg capsule
Take 25 mg by mouth 2 (two) times a day.
•UNKNOWN TO PATIENT
Seriphos
Prempo 0.625mg/2.5 mg tab
•venlafaxine (EFFEXOR XR) 75 mg ER tablet
Take 75 mg by mouth daily.
ROS:
As per HPI
Physical Exam:
Vitals:
Vitals:
10/06/21 1544
BP:134/91
Site:Left Arm
Position:Sitting
Pulse:92
SpO2:96%
Weight:72.4 kg (159 lb 9.8 oz)
Height:1.689 m (5' 6.5")
General: Well-appearing woman
Resp: Breathing comfortably on room air
CV: Warm, well-perfused. Peripheral pulses intact
MSK: no obvious deformities
Neurological Exam:
Mental Status: Awake, alert. Very bradyphrenic. Very slow to answer questions, sometimes needing repetition
Cranial Nerves:
II: PERRL. VF intact with finger counting.
III/IV/VI: EOMI without nystagmus
V: Facial sensation intact
VII: Facial musculature intact with forceful eyelid closure, symmetric smile
VIII: Hearing roughly intact bilaterally
IX/X: Palate and uvula midline
XI: Shoulder shrug intact
XII: Tongue midline
Motor:
Bulk: normal
Tone: normal
Voluntary movements: bradykinetic
Involuntary movements: no tremor
Strength: No pronator drift. Normal finger taps. 5/5 throughout the upper and lower extremities proximally and distally
Sensory:
Light touch: intact in the upper and lower extremities
Vibration: mildly reduced in the toes
Reflexes:
Right
Left
Biceps
2+
2+
Brachioradialis
3+
3+
Triceps
2+
2+
Patellar
2+
2+
Ankle Jerk
2+
2+
Hoffman's
present
present
Babinski
absent
absent
Coordination: No dysmetria with finger to nose bilaterally.
Gait: Normal stance and stride. Arm swing normal and symmetric. Normal toe, heel and tandem walk.
Assessment: This is a 75-year-old woman with no significant past medical history who presents with progressive cognitive decline, imbalance, and depression following a head injury with LOC. It is possible that this is due to post-concussion syndrome, however given her age and progressive decline, consider a primary neurodegenerative process. Secondary causes such as a subdural hematoma should also be evaluated with imaging. Her imbalance could also be due to neuropathy given mildly decreased vibratory sense in feet, though this is less likely given preserved ankle jerks.
Plan:
- Neuropathy and dementia lab screening
- MRI brain
- Referrals made to PT and neuropsych
- Return in about 3 months (around 1/6/2022).
Sakinah Sabadia, MD
Clinical Assistant Professor
Department of Neurology
Patient Instructions - Clinical Notes
Sakinah B Sabadia, MD at 10/6/2021 4:00 PM
- Schedule MRI of the brain
- Blood work today
- Referrals made for Neuropsychology and Physical Therapy
Blood work results from test on 10/6/21:
PROTEIN, TOTAL
Your Value
7.2 g/dL
Standard Range
6.3 to 8.2 g/dL
6.3 - 8.2 g/dL
ALBUMIN PROTEIN ELECTROPHORESIS
Your Value
4.07 g/dL
Standard Range
3.75 to 5.01 g/dL
3.75 - 5.01 g/dL
ALPHA-1-GLOBULIN
Your Value
0.35 g/dL
Standard Range
0.19 to 0.46 g/dL
0.19 - 0.46 g/dL
ALPHA-2-GLOBULIN
Your Value
1.10 g/dL
Standard Range
0.48 to 1.05 g/dL
0.48 - 1.05 g/dL
BETA GLOBULIN
Your Value
0.94 g/dL
Standard Range
0.48 to 1.10 g/dL
0.48 - 1.10 g/dL
GAMMA GLOBULIN
Your Value
0.74 g/dL
Standard Range
0.62 to 1.51 g/dL
0.62 - 1.51 g/dL
SPE INTERPRETATION
Your Value
NO MONOCLONAL PROTEIN SPIKE DETECTED.
INCREASED ALPHA 2 GLOBULIN CONSISTENT WITH ACUTE INFLAMMATION.
Performed by NYU Langone Hospitals, Tisch Labs. 560 First Avenue, NY, NY,
10016. CLIA: 33D0653358, PFI: 5153 Director: Maria E. Aguero Rosenfeld MD.
General Information
Ordered by Sakinah B Sabadia, MD
Collected on 10/06/2021 5:52 PM from Peripheral (blood)
Resulted on 10/07/2021 3:06 PM
Result Status: Final result
This test result has been released by an automatic process.
_________________________________
10/1/21 AARP Medicare plan Part F and RX is activated