12/20/24, 12:57 PM Print Preview
POTTER GERGEL, Alessandra DOB: 04/14/1988 (36 yo F) Acc No. 50781 DOS:
11/12/2024
Progress Notes
Patient: Potter Gergel, Alessandra
Provider: Collina Afriyie
Account Number: 50781
DOB: 04/14/1988 Age: 36 Y Sex: Female Date: 11/12/2024
Phone: 240-586-3925
Address: 7206 LIMESTONE LN, MIDDLETOWN, MD-21769
Pcp: Julio Menocal
Subjective:
Chief Complaints:
1. Headaches.
HPI:
General neurology - new patient:
The patient is a 36 yo female currently 32 y/o female with a h/o epilepsy, alcohol abuse and migraines and
cluster headaches. She was last seen on 09/17/2024. She has been taking verapamil with benefit even tension
type headaches. She had pneumonia in 10/2024 and was off verapamil for a week and she had a cluster
headache. She has not had a migraine/tension or cluster headache since resuming verapamil. She denies side
effects.
Last visit's HPI:
The patient is a 36 yo female currently 32 y/o female with a h/o epilepsy, alcohol abuse and migraines and
cluster headaches. She was last seen on 12/06/2023. She has been having frequent headaches. Headaches are
behind both eyes and daily. Associated sx include photophobia and phonophobia. She notes to have about 5
seizures aura a few weeks ago and notes this happened whiles she was going to sleep. She denies any
convulsions. She describes this as "feeling of terror, everything looks different and "impending sense of doom".
She has been on Keppra 1000mg TID. She was taking medication when this happened and notes to have been
very stressed. She has an MRI brain scheduled in a few days. She also c/o short term memory loss and word
finding difficulty.
ROS:
All:
General: no problems,. Lungs: no problems,. Heart: no problems,. Gastrointestinal no problems,.
Genitourinary: no problems,. Muscle & Joints: no problems,. Neurological: no problems,. Sleep: no
problems,. Hematological: no problems,. Lymphatic: no problems,.
Medical History: Anxiety, Depression, Autism, ADHD, Interictal Behavior Syndrome, Left temporal lobectomy
-2002.- tumor assumed benign.
Surgical History: Tonsillectomy 2010, Adnoidectomy 2010, Gallbladder removal 2011, Ankle surgery , Abortion
, C-section 2019, Ovarian cyst removal 2022, L Mesial temporal lobectomy 9/2002, Appendectomy 3/2022.
Hospitalization/Major Diagnostic Procedure: Denies Past Hospitalization.
Family History: Father: alive, diagnosed with Diabetes. Mother: alive, diagnosed with Diabetes, Hypertension,
Mental Illness. Siblings: alive. Grandparents: alive. 3 brother(s) . 2 son(s) , 1 daughter(s) . .
Social History:
Alcohol: Points: 1, Interpretation: Negative.
Smoking
Are you a: current smoker
How many cigarettes a day do you smoke? 6-10
How soon after you wake up do you smoke your first cigarette? 6-30 min
Are you interested in quitting? Ready to quit
Medications: Taking Quviviq 25 MG Tablet 1 tablet within 30 minutes of bedtime Orally Once a day, Taking
Amphetamine-Dextroamphet ER 30 MG Capsule Extended Release 24 Hour 1 capsule in the morning Orally Once
a day prn, Taking Albuterol Sulfate , Notes: PRN, Taking Propranolol HCl 10 MG Tablet 1 tablet on an empty
stomach Orally Twice a day, Taking Acamprosate Calcium 333 MG Tablet Delayed Release 2 tablets Orally Three
Provider: Collina Afriyie Date: 11/12/2024
1/4
12/20/24, 12:57 PM Print Preview
POTTER GERGEL, Alessandra DOB: 04/14/1988 (36 yo F) Acc No. 50781 DOS:
11/12/2024
times a day, Taking QUEtiapine Fumarate 25 MG Tablet 1 tablet at bedtime Orally As needed, Notes: 25-75mg 2
bedtime, Taking LaMICtal XR 100 MG Tablet Extended Release 24 Hour 1 tablet Orally Once a day, Taking Keppra
1000 MG Tablet 1 tablet Orally Three times a day, Taking Naltrexone HCl 50 MG Tablet 1 tablet Orally Once a day,
Taking Verapamil HCl 40 MG Tablet 1 tablet Orally Three times a day, Not-Taking diazePAM 2 MG Tablet 1 tablet
as needed Orally As needed, Not-Taking Temazepam 30 MG Capsule 1 capsule at bedtime as needed Orally Once
at night, Not-Taking Nurtec 75 MG Tablet Disintegrating 1 tablet on the tongue and allow to dissolve Orally every
other day, Not-Taking Adderall XR 20 MG Capsule Extended Release 24 Hour 1 capsule in the morning Orally
Once a day, Not-Taking BuSpar , Notes: 10mg, Not-Taking Venlafaxine HCl ER 75 MG Capsule Extended Release
24 Hour 1 capsule with food Orally Once a day, Medication List reviewed and reconciled with the patient
Allergies: Morphine, Fluconazole.
Objective:
Vitals: BMI: 30.11, BP Sit: 126/79, Ht: 63, Pulse, sitting: 63, Wt: 170.
Physical Examination:
General:
Appearance: alert, well nourished.
HEENT:
Head: normocephalic.
Nasal patency: open, bilaterally.
Musculoskeletal:
Lower extremity joints: unremarkable.
Upper extremity joints: unremarkable.
Neurological:
Cranial nerves:
I. normal (subjective)
, CN II. Visual fields:
normal to confrontation testing
, CN III. Pupils: equal, reactive to light and accomodation, round,
, CN III, IV and VI. EOM:, No ptosis or nystagmus, full with normal pursuit and saccade,
, CN V. Trigeminal: , normal facial sensation and ability to clench jaw
, VII. No asymmetry or weakness
, VIII. Actuity intact to finger rub bilaterally
, XI. Sternocleidomastoid, trapezius strength intact
.
Gait: Base:, normal, Stance:, normal.
Motor Strength: no cogwheeling,
RIGHT UPPER EXTREMITY: , 5/5 in deltoid abduction, biceps flexion, extension and flexion, tone
normal, LEFT UPPER EXTREMITY:, 5/5 in deltoid abduction, biceps flexion, extension and flexion, tone
normal, RIGHT LOWER EXTREMITY:, 5/5 strength in hip flexion, extension and abduction, foot
Provider: Collina Afriyie Date: 11/12/2024
2/4
12/20/24, 12:57 PM Print Preview
POTTER GERGEL, Alessandra DOB: 04/14/1988 (36 yo F) Acc No. 50781 DOS:
11/12/2024
dorsiflexion and plantar flexion, knee extension and flexion, LEFT LOWER EXTREMITY:, 5/5 strength in
hip flexion, extension and abduction, foot dorsiflexion and plantar flexion, knee extension and flexion.
Pronator drift: not present.
Reflexes: Knees:, 2+, bilateral.
Psychology:
Orientation to person: normal.
Orientation to place: normal.
Orientation to time: normal.
Assessment:
Assessment:
1. Cluster headache syndrome, unspecified, not intractable - G44.009 (Primary), 11/12/2024 Controlled on
verapamil without side effects. Will continue. 09/17/2024 She reports cluster headaches every 3m. She has MRI
brain is scheduled for a few days. She will start verapamil and monitor her blood pressure to monitor for
hypotension. 12/07/2023 Verapamil was not started last visit, she had a recent cluster headache in 11/2023 but
unfortunately was unable to take sumatriptan as she is pregnant. We did discuss starting verapamil as a
preventative. She will clear this with OB first. 09/07/2022 MRI brain showed "small focus of nodular
enhancement at the superior margin of the surgical resection cavity which may represent post surgical change"
Will plan on repeat MRI in 3 months to check for stability. Will start verapamil for cluster headaches. 08/10/22
DDX include- Cluster headaches, migraines I will order MRI brain w/wo for further evaluation and to r/o a lesion
2. Anxiety disorder, unspecified - F41.9, Sees Psychiatrist- -Sheppard Pratt Charlene Rozich- NP
3. Depression, unspecified - F32.A, sees psychiatry
4. Epilepsy, unspecified, not intractable, without status epilepticus - G40.909, 11/12/2024 No tonic clonic seizure
since last visit (last known is 2005). Lamictal from psychiatrist has helped but she had a aura a week ago when
she was very stressed. I Will continue titration to 100mg BID and get a level. I will give her valtoco for the aura.
She has a h/o addiction and is strongly advised to use this only as needed. 09/17/2024 She describes a seizure
aura but no convulsions. She has started Lamictal from psychiatry and is currently titrating. We discussed since
this is an AED, it is beneficial to prevent future seizures. 12/06/2023 No new events or stroke like sx since last
visit. She did say she is having side effects with Keppra. We talked about titrating her Lamictal to a therapeutic
dosage once she delivers her baby. 09/07/2022 No event or seizure like sx since last visit. 08/10/2022 last
seizure was in 2005
5. Celiac disease - K90.0, 12/06/2023 F/u with with GI 08/10/2022 will order blood work and have her f/u with
gastroenterology for this
6. Migraine without aura, not intractable, without status migrainosus - G43.009, 11/12/2024 She has not had a
migraine since starting verapamil. She is yet to get nurtec, waiting on PA. 09/17/2024 She reports to have had
side effects with Topamax. Will trial her on nurtec Potential side effects discussed
7. Other specified disorders of brain - G93.89, 11/12/2024 MRI brain did not show a change from previous
imaging. MRI findings are known to be from previous lobectomy from a benign tumor. 09/17/2024 MRI brain
scheduled in a few days. 12/07/2023 She did not complete MRI brain. Will provide another order to evaluate
stability of nodular enhancement seen on previous imaging. 09/07/2022 repeat MRI BRAIN in 3mo
8. Other insomnia - G47.09, 12/07/2023 She inquires about prescription for temazepam but is advised to discuss
this with her OB, as previous prescription was one time and she is currently pregnant. 09/07/2022 One time
prescription given for temazepam which pt used to be on. She is also on quetipine but tapering off. She will
discuss with her psychiatrist
9. Unspecified symptoms and signs involving cognitive functions and awareness - R41.9, 09/17/2024 She admits
to short term memory loss and word finding difficulty. We discussed potential causes, daily headaches,
depression/anxiety having a role. Will refer her for a Neurospych eval but she is advised to monitor after
headache is controlled.
10. Benign neoplasm of brain, unspecified - D33.2
08/31/22 MR Brain W WO
Status post left temporal lobectomy with postsurgical changes. There is a small focus of nodular enhancement at
the superior margin of the surgical resection cavity which may represent post surgical change however if prior
films are not available, recommend short-term follow-up MRI in 3 months to confirm stability. Single focus of
Provider: Collina Afriyie Date: 11/12/2024
3/4
12/20/24, 12:57 PM Print Preview
POTTER GERGEL, Alessandra DOB: 04/14/1988 (36 yo F) Acc No. 50781 DOS:
11/12/2024
increased T2/FLAIR signal involving the left frontal white matter which is of unlikely clinical significance.
09/19/2024 MR Brain W WO
IMPRESSION: Stable postoperative changes within the left temporal lobe, with a stable nodular focus of
abnormal T2 prolongation within the temporal lobe adjacent to the surgical cavity measuring 1.6 x 0.7 x 1.1 cm.
This does not enhance, and shows no appreciable change in its size or configuration from the previous
examination. This is likely postsurgical in nature.
The remainder of the brain parenchyma is unremarkable, with no evidence for acute hemorrhage or infarct. No
mass effect is demonstrated.
Stable exam.
Plan:
1. Cluster headache syndrome, unspecified, not intractable
Start Verapamil HCl Tablet, 40 MG, 1 tablet, Orally, Three times a day, 30 day(s), 90, Refills 2 .
Imaging: MRI Brain +/-
2. Epilepsy, unspecified, not intractable, without status epilepticus
Start Valtoco 5 MG Dose Liquid, 5 MG/0.1ML, as directed, Nasally, take at onset of aura, 30 days, 5 .
LAB: Lamotrigine (Lamictal), Serum
LAB: Keppra
LAB: CMP
3. Migraine without aura, not intractable, without status migrainosus
Start Nurtec Tablet Disintegrating, 75 MG, 1 tablet on the tongue and allow to dissolve, Orally, every other day,
30 days, 16, Refills 5 .
4. Others
Notes: PLAN
Continue verapamil
Increase lamictal- 50AM, 100pm for two weeks, then 100AM, 100PM ongoing- She has enough 25mg to titrate.
She may call for a refill.
Continue Keppra- refilled by PCP
Nurtec as needed
MRI BRAIN WO/W- 09/2025
Avoid hazardous activities, such as mountain climbing or scuba diving. A seizure under these conditions could
lead to a fatal accident/ No operating of heavy machinery for 3months after last seizure
Don't swim alone or participate in other similar activities without others nearby.
Maryland law requires patients who have lost consciousness to contact the Motor Vehicles Administration
Preventive Medicine:
Counseling:
Exercise .
Health .
smoking cessation and alcohol cessation discussed.
Images:
Provider: Collina Afriyie Date: 11/12/2024
4/4
