SUBJECTIVE: The patient presents today for followup of his facial pain, probably atypical facial pain over many years. It had worsened the last time we saw him, but it ended up being a tooth-related pain. This was corrected and he has a low level pain as he has had for many years without changes. Otherwise, there are no evolving signs whatsoever.
A CT scan of the head in the area of the excision of the right maxillary melanoma did not reveal any major abnormalities. He does not have any new complaints whatsoever. He feels quite stable. He went off the Neurontin and is not interested in any other medications at this time. This was a followup to ensure that there are no evolving signs.
OBJECTIVE: Visual fields, extraocular eye movements normal. Corneal reflexes were equal bilaterally. There is no ptosis. Facial sensation and movement are normal. Pinprick, light touch, temperature in the face were all normal. Symmetrical tongue and palate. Oropharyngeal sensations are normal and equal bilaterally. Hearing is equal bilaterally. Sternocleidomastoids are strong with normal bulk bilaterally. There are no masses, lymphadenopathy or rashes across the face or in the neck. Minimal point tenderness over the neck. The rest of his neurological examination remains quite stable. There are no evolving cranial neuropathies.
ASSESSMENT AND PLAN: The patient is doing quite well. If he were to have any problems with increasing atypical facial pain or neuralgia, he should come back to the hospital for evaluation.
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SUBJECTIVE: This is an (XX)-year-old female who is known to me and returns for a followup accompanied by her son. We discussed the results of the scans that we completed recently. I explained to her some of the findings. The brain does not demonstrate any acute changes. There is stable meningioma. Small vessel microangiopathic changes were noted as well, but again nothing acute. The patient’s thoracic and lumbar spine MRI demonstrates spondylitic multilevel degenerative disk disease.
ASSESSMENT AND PLAN: I told the patient and her son that, for now, her symptoms could be multifactorial with evidence suggesting perhaps some of the symptoms may be emanating from the vestibular system with some otolith dysfunction, as it appears that some of the symptoms of feeling unsteady and dizzy seem to resolve after significant head and neck movement.
On the other hand, she is also unsteady, probably from a combination of other factors, including spondylitic changes, neuropathy and white matter disease. It is reasonable to pursue physical therapy for now, and the patient is agreeable. We will arrange for her to have physical therapy in the future.
