Neurology Chart Note-MT Homework

Hi! I was wondering if anyone could help me with this chart note. I am enrolled in the Medical Transcription Program through PCDI. It is an at-home course and I don't have great resources when I have a question or need help with some of the work. I have looked other places for a sample of a Neurology chart note but was unable to find one. I know without actually hearing the dictation, it may be hard to help me. But any advice, assistance with formatting, or pointing out of any errors would be greatly appreciated. Thank you. CHART NOTE This is a 22-year-old college senior who has has lightheadedness and dizzy spells going back a number of years but apparently, he never paid much attention to these spells until he had a seizure last year. He has so far had only one definite witnessed episode of grandmal seizure. He lost conscienousness and was witnessed to have jerking of the extremities. He did not have any tongue biting or incontinence. He has continued to have episodes of dizziness or lightheadedness and has been on Dilantin 100 mg orally t.i.d. since early July. On specific questioning, he recalls having had an episode while he was ushering at a light show. A blinking effect brought back memories of his seizure and he felt dizzy. He also recalls feeling somewhat nauseaed during these dizzy spells but denied having other symptoms of peculiar odor or taste during any of these episodes. He denies any other symptoms suggestive of jamais vu or deja vu and he denies any neurologic symptoms like head injury or episodes of vertigo, diplopia, frequent headaches, numbness, weakness, ataxia, etc. NEUROLOGICAL EXAM: Mental status seems entirely normal. Cranial nerves II through XII are intact. Sensory exam to light touch, pin ***** position, and vibration are completely normal and so are cortical sensations. Stereognosis is intact. Motor exam reveals normal tone and power. Deep tendon reflexes are bilaterally 2+. Plantars are downgoing. Finger-to nose, heel-to-shin, and tandem walking were well performed. Romberg's test was negative. IMPRESSION: This patient has a normal neurological exam. It sounds as if he had had at least one episode of generalized seizure and he continues to have episodes of dizziness or vagueness. He's already had a workup including a CT scan of the head with and without contrast, which was normal, an abnormal EEG with nonspecific slowing, and normal labwork including a normal DTT, CBC, SMAC, and urine catecholamines. If he continues to have definite seizures in spite of being on Dilantin, then he might be a candidate for a different anticonvulsant like Tegretol. Before making this change, I've rescheduled him for a sleep-deprived EEG with NP leads and will also obtain a Dilantin level. Depending on the results of those two studies, we will either plan on increasing his Dilantin dosage or changing him to Tegretol.