DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
CONSULTANT: John Doe, MD
REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed male with history of hypertension, previous CVA, residual spastic left hemiplegia, seizures, alcohol abuse in the past, coronary artery disease status post coronary artery bypass graft, and most recent possible brainstem cerebrovascular accident about 8 months ago. He was admitted to the hospital with confusion and was wandering around. Reportedly, the patient was found wandering around on the road, in his car, driving erratically. The patient has no clear recollection of events. He was brought to the emergency room and was completely disoriented. No reports of any complete loss of consciousness or any witnessed tonic-clonic seizure activity. The patient states that he was taking his Dilantin, but he does not remember if he had any seizures. He has no idea of how he got to the hospital. At this time, the patient denies any new focal neurological symptoms. CT of the head without contrast from the emergency room was reported as negative for any acute lesions.
PAST MEDICAL HISTORY: Essentially as stated above. He also had abdominal aortic aneurysm repair and left leg femoropopliteal bypass.
MEDICATIONS ON ADMISSION: Neurontin 300 mg t.i.d., Plavix 75 mg once a day, Lanoxin, K-Dur, folic acid 1 mg once a day, vitamin B6 50 mg a day, TriCor 160 mg a day, multivitamins, Dilantin 250 mg a.m. and 300 mg nightly, Seroquel 25 mg nightly, Prozac 10 mg daily, Protonix 40 mg once a day, and Ativan 1 mg t.i.d.
ALLERGIES: HE HAS NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He smokes 3 packs a day. He had a long history of alcohol abuse but claims that he quit.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: General: The patient is an averagely built male, who is not in acute distress. Vital Signs: Stable, as noted on the chart. HEENT: Examination unremarkable. Neck: Supple. No carotid bruits. Heart: S1 and S2 are normal. No murmur, gallop, or rub. Lungs: Clear. Neurologic: He is alert. He knows he is in the hospital. He has no recollection of events from yesterday, clearly. He follows commands appropriately. His speech is dysarthric, which is unchanged from his previous exams. Pupils are 3 mm, round, reactive to light and accommodation. No visual field defects. Extraocular movements are full and no nystagmus. Mild left facial weakness of central type is still seen, residual from previous stroke. Auditory canals are intact. He appears to be swallowing fairly well. Motor examination reveals spastic left hemiparesis. Strength is 0/5 in the left upper extremity and 3 to 4/5, left lower extremity, which is unchanged from previous one, 5/5 on the right side. Generalized hyporeflexia. Plantar response is downgoing on the right, upgoing on the left.
LABORATORY DATA: Laboratories on admission; blood gases show pH 7.40, PCO2 41.6, PO2 62.2. O2 saturation 91.9. Urine drug screening came back positive for benzodiazepines and cannabinoids. CK, myoglobin was elevated. Troponin was normal. CBC shows WBC 6900, H and H 12.4 and 39. Platelets normal at 262,000. Chemistry profile on admission shows sodium 144. Rest of the electrolytes are normal. BUN, creatinine, and blood sugar were normal. Liver profile was unremarkable. Dilantin level on admission was 4.3.
CT head without contrast, no acute focal lesions.
1. Altered mental status, confusion, could be metabolic encephalopathy, rule out sepsis versus seizure, in postictal state.
2. Old brainstem cerebrovascular accident and also spastic left hemiparesis, nonplegic, residual from previous stoke.
3. Seizure disorder with subtherapeutic Dilantin level.
4. History of alcohol abuse in the past but sober now.
5. Multiple medical problems including cardiac and peripheral vascular disease.
RECOMMENDATIONS: We will give extra Dilantin bolus of 500 mg intravenous piggyback today and check the level in the morning. He denies doing any drugs. However, his urine drug screen tested positive for marijuana. Protonix sometimes gives false-positive results for marijuana.
Thank you, Dr. Doe, for the consult. We will follow the patient with you.