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Intracranial Hemorrhage Medical Transcription Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Intracranial hemorrhage.

HISTORY OF PRESENT ILLNESS:  The history was obtained from the patient's wife at length. No old records were available, including records of recent hospitalization. The patient is apparently a poor historian because of dementia. This is a (XX)-year-old right-handed gentleman who five days ago was admitted initially to an outside hospital and then transferred to another hospital after a car accident. His brain imaging studies revealed left parietal hemorrhage. According to his wife, the patient had an MRI scan of the brain, which revealed evidence of cerebral amyloid angiopathy. The patient has hypertension and stayed in the ICU for several days to control the blood pressure. On their request, the patient was transferred two days ago here. The patient was sent to have vascular studies of the lower extremity for DVT, which was negative, but on his way back, he struck his head to the window of the ambulance. The patient underwent CT scan of the brain, which again revealed parietal parenchymal hemorrhage, but no evidence of any acute bleed on the left side where he was struck. For several months, the patient's cognitive functions have been declining slowly. He has been noticed to have been confused and at times wandering. His blood pressure also has been fluctuating. His blood pressure medicines were being adjusted recently.

PAST MEDICAL HISTORY:  As above. History of hypertension, history of recently progressive cognitive deficit and he was started on Aricept for that reason. The patient has no history of head trauma. He has no history of seizures.

CURRENT MEDICATIONS:  Include lisinopril, Zestril, Aricept, and Proscar.

FAMILY HISTORY:  The patient's mother died of brain hemorrhage. His father died of heart disease. He has one older sister, who has Parkinson's disease.

SOCIAL HISTORY:  The patient smokes two to six cigarettes a day. He occasionally drinks alcohol. There is no history of illicit drug use.

REVIEW OF SYSTEMS:  As per the history of present illness. No additional pertinent information was obtained.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-developed and well-nourished man, who is not in any apparent distress.
VITAL SIGNS:  Blood pressure is 150/90, pulse is 74, respiratory rate is 18, and temperature 98.4.
NECK:  Supple. There are no carotid bruits.
HEART:  Rate and rhythm are regular.
HEENT:  Head is atraumatic and normocephalic.
CHEST:  Clear.
ABDOMEN:  Soft. There is no peripheral edema.
NEUROLOGIC:  The patient is awake and alert. He is oriented to person and time, although he did not know the date. He is oriented to place, but he could not tell me the room number or floor. Short-term memory is 1/3 at 5 minutes. Attention and concentration are mildly impaired. Speech is fluent. Cranial Nerves:  Pupils are equal and reactive. Visual fields on examination revealed left-sided visual field defect and visual extension on the left side. There is very mildly decreased left facial nasolabial fold. Tongue is midline.  Motor:  There is no drift. Strength seems to be 5/5 in all four extremities. Sensations are intact to pinprick, but the patient has sensory neglect on the left side. Gait is unsteady. Attention and coordination are normal.

DIAGNOSTIC STUDIES:  Reviewed the CT scan of the brain done two days ago and the findings are as described before. There is mild mass effect also.

IMPRESSION:
1.  Subacute left parietal parenchymal hemorrhage. The location of the hemorrhage is not typical of hypertensive, but hypertension probably has contributed to the hemorrhage. Underlying etiology likely is cerebral amyloid angiopathy.
2.  Cerebral amyloid angiopathy.
3.  Mild to moderate dementia, also probably related to cerebral amyloid angiopathy.
4.  Uncontrolled hypertension.

RECOMMENDATIONS:  At this time, blood pressure control is of prime importance. We will review old records from outside hospital, which have been requested and are awaited. We will observe fall precautions and use restraints if needed. Continue physical and occupational therapy as well as gait training. We will continue the patient on Aricept and increase the dose in three to four weeks to 10 mg daily.

Thank you, Dr. John Doe, for letting me participate in the care of the patient.