AI Scribe for Neurologists

SUBJECTIVE:
42-year-old right-handed female with relapsing-remitting multiple sclerosis (dx 2019, JCV antibody negative) presents for routine 6-month follow-up. Currently on ocrelizumab 600mg IV every 6 months, last infusion 11 weeks ago. Reports stable function since prior visit. No new neurologic symptoms - no optic symptoms, no new sensory changes, no Lhermitte sign. Continues on vitamin D3 5000 IU daily. Sleep adequate. Walks 30 minutes daily without aid. Works full-time as a paralegal. No urinary urgency. Denies cognitive complaints, though notes occasional word-finding pauses she attributes to multitasking.

Reviewed: ocrelizumab risks (PML, infusion reaction, hep B reactivation), screening labs current.
ROS otherwise negative.

OBJECTIVE:
Vitals: BP 118/74, HR 68, RR 14, Wt 64 kg, Temp 98.0F

Mental Status: Alert, oriented x3. Fluent speech. MoCA not formally administered today.

Cranial Nerves:
- II: Visual acuity 20/20 OU corrected. No RAPD. Disc margins sharp bilaterally. Visual fields full to confrontation.
- III, IV, VI: EOMI without nystagmus or INO. No diplopia on extreme gaze.
- V: Sensation intact V1-V3 bilaterally. Masseter and temporalis strength symmetric.
- VII: Symmetric facial movement. No flattening.
- VIII: Hearing grossly intact bilaterally to finger rub.
- IX, X: Palate elevates symmetrically. Gag intact.
- XI: SCM and trapezius 5/5 bilaterally.
- XII: Tongue protrudes midline.

Motor: 5/5 throughout - deltoids, biceps, triceps, wrist ext, finger flex, hip flex, knee ext, ankle dorsiflex, EHL bilaterally. No drift on pronator drift testing. No fasciculations.
Tone: Mildly increased in right lower extremity (spastic catch at the knee). Otherwise normal.
Sensory: Intact light touch, pinprick, vibration, proprioception throughout. No sensory level on chest or back.
DTRs: 3+ at biceps, brachioradialis, patellar, achilles bilaterally. Symmetric. Plantar responses flexor bilaterally. No clonus.
Coordination: FNF and HKS smooth bilaterally. Rapid alternating movements normal.
Gait: Normal-based, normal stride length. Tandem gait intact for 10 steps. Romberg negative.
EDSS today: 1.5 (no disability, minimal signs - mild RLE spasticity).
EDSS prior visit (Oct 2025): 1.5. Stable.

MRI brain and C-spine (3 weeks ago, with and without contrast):
- Brain: Stable T2/FLAIR lesion burden in periventricular and juxtacortical white matter. No new T2 lesions. No enhancing lesions. No new black holes.
- C-spine: Stable C2-C3 cord lesion. No enhancement. No new lesions.
Compared to prior MRI (Oct 2025): No radiographic disease activity.

Labs (today): CBC normal, CMP normal, IgG 920 mg/dL (low-normal), JCV index 0.18 (negative).

ASSESSMENT:
1. Relapsing-remitting multiple sclerosis (G35) - clinically and radiographically stable on ocrelizumab. NEDA-3 status maintained over the past 6 months. EDSS 1.5, unchanged.
2. Mild right lower extremity spasticity - chronic, non-disabling, not requiring pharmacologic treatment.
3. Vitamin D supplementation - continue 5000 IU daily, last 25-OH vitamin D level 42 ng/mL.

PLAN:
1. Continue ocrelizumab 600mg IV every 6 months. Next infusion scheduled in 13 weeks - pre-infusion labs (CBC, CMP, hep B panel, IgG/IgM) and a brief telehealth check-in 1 week prior.
2. Repeat MRI brain and C-spine without contrast in 12 months given radiographic stability and JCV negativity. If new symptoms develop, advance imaging.
3. Continue vitamin D3 5000 IU daily.
4. Counseled on relapse symptoms warranting urgent contact - new vision change, new weakness, new sensory level, new bowel/bladder dysfunction, new gait change.
5. Influenza and Tdap vaccines - given more than 2 weeks before next infusion, encouraged today.
6. Return to clinic in 6 months, sooner for any new symptoms.

Billing: 99214. Moderate complexity - one chronic, stable problem on a high-risk parenteral therapy with imaging and labs reviewed. CPT 96365 will be billed by infusion suite at next infusion encounter.

ICD-10: G35