Neurology Follow-Up Clinic Letter

Neurology Follow-up Clinic Letter Diagnosis: Migraine with Aura Other Diagnoses: 1. Essential Hypertension 2. Generalized Anxiety Disorder Current Medications: 1. Topiramate 50 mg BID 2. Propranolol 20 mg daily 3. Lisinopril 10 mg daily 4. Sertraline 50 mg daily Management Plan: 1. Increase Topiramate to 75 mg BID for better migraine prophylaxis. 2. Continue Propranolol 20 mg daily. 3. Continue Lisinopril 10 mg daily. 4. Continue Sertraline 50 mg daily. 5. Recommend a course of occipital nerve blocks if migraine frequency does not improve with Topiramate adjustment. 6. Refer to cognitive behavioural therapy (CBT) for anxiety management. I followed up with this lady in the neurology clinic. She reports a slight improvement in migraine frequency and severity since her last visit three months ago, but still experiences 8-10 migraine days per month, often preceded by visual aura. The character of the aura remains consistent, described as flashing lights and zig-zag lines. She denies any new neurological symptoms such as weakness, numbness, or changes in speech or vision outside of the migraine aura. Her anxiety symptoms are stable with her current medication, but she acknowledges the need for additional coping strategies. She tolerates her current medications well, with no significant side effects reported. Physical Examination: Mental Status: Alert and oriented to person, place, and time. Speech clear and fluent. Cognition grossly intact. Cranial Nerves: Pupils equal, round, and reactive to light. Extraocular movements full. Visual fields full to confrontation. Facial sensation intact. Facial symmetry preserved. Hearing intact to whispered voice. Palatal elevation symmetrical. Tongue protrudes in midline. Sternocleidomastoid and trapezius strength 5/5 bilaterally. Motor Function: Upper and lower extremity strength 5/5 bilaterally. No fasciculations or atrophy. Tone normal. Sensory Function: Sensation intact to light touch, pinprick, vibration, and proprioception in all extremities. Reflexes: Deep tendon reflexes 2+ and symmetrical throughout. Plantar reflexes downgoing bilaterally. Coordination: Finger-to-nose and heel-to-shin smooth and accurate bilaterally. Rapid alternating movements performed without dysmetria. Gait: Steady and well-coordinated, narrow-based. Romberg negative. Opinion and Recommendations: My clinical impression is that of chronic migraine with aura, with partial response to current prophylactic therapy. Her generalized anxiety disorder is well-controlled on current medication. The plan is to escalate Topiramate dosage to achieve better migraine control and monitor for side effects. Referral to CBT is recommended for her anxiety. We will schedule a follow-up appointment in three months to review treatment efficacy and tolerability.