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Neuro Consult Medical Transcription Sample Report

REASON FOR CONSULTATION:  Subarachnoid hemorrhage.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old man with prior history of stroke and residual hemiplegia.  He fell, struck his head, and developed a large left subdural with left traumatic subarachnoid hemorrhage.  In the emergency room, he was not following commands and acting odd relative to baseline, reportedly.  In the ER, he could follow commands with the left side but had a known right hemiplegia.  He was also apparently aphasic.  This was known prior to admission.  A followup head CT done on hospital day number six showed no change, and because the patient was not deemed a neurosurgery candidate, he was transferred to the medical unit.  He had some sinus pauses and sinus tachycardia with ectopy during his stay.  He had an NG tube for nutrition and developed a wound on his left foot.  DVT screening was normal.  He was sent to this facility on pneumatic boots.  Apparently, the patient was taking p.o.  He was drinking Boost t.i.d.  The patient is frustrated and angry and at times would scream out.

PAST MEDICAL HISTORY:  CAD, hypertension, and remote stroke with right hemiparesis.

Initial head CT reports thin subdural in the left cerebral convexity, small right frontal contusion, small left temporal contusion with subarachnoid blood, small right frontal subdural, minimal midline shift from right to left, significant subcortical white matter disease, old right craniotomy evidence, and probable old injury to the left orbital roof.  CT of the cervical spine was clear.  Followup head CT showed no change.  There is no history of seizure in this patient.  They do not mention seizure during his hospitalization this admission.

MEDICATIONS:  Dilantin 250 mg b.i.d., Keflex q.6 hours, Lopressor 50 mg daily, Norvasc 5 mg daily, Pepcid 20 mg b.i.d., and Plavix.

ALLERGIES:  Aspirin.

FAMILY HISTORY:  Unknown.

SOCIAL HISTORY:  Not documented in the chart.  There is no one in the room to report.  Apparently, he has strong family support and lives with his sister.

REVIEW OF SYSTEMS:  Unobtainable.

PHYSICAL EXAMINATION:  At 5 p.m., the patient was lying in bed with an NG tube, asleep.  His left arm is in a restraint.  Four days ago, his temperature was 101 degrees.  Heart rates have been up in the high 150s from time to time as well.  Currently, pulse O2 saturation is 80% on room air.  The patient was placed on 2 liters.  Vitals still with temperatures of 101 to 100 degrees, and Doppler today showed a DVT in the right and left common femoral veins.  Vitals:  Pulse 160.  Temperature as above.  Respirations 16.

He lays in bed asleep.  Sternal rub, pinching his shoulder blades, bowel pressure did not arouse him.  He briefly opens his eyes.  He does not attempt to phonate.  He follows no commands.

Cranial nerve examination is remarkable for nonvisualized fundi.  Pupils with minimal reactivity but equal.  Gaze deviation to the left, right seventh cannot judge, blinked to threat, visual fields.  Tongue is midline in his mouth.  Palate appears symmetric with lot of built-up secretions in his mouth.  Difficult to see his posterior pharynx.  Motor:  Right hemiplegia with increased tone proximally and in the hand as well.  Minimal withdrawal to pain in the right leg and no movement in the right arm.  Left arm and leg, he moves volitionally and semi-purposefully.  He appears to grimace to pain on the left but not on the right.  Toes are down bilaterally.  Reflexes are absent in the knees and ankles, 2 in the right elbow, otherwise absent in the left arm.  No frontal release signs.  Could not assess gait or his cerebellar exam.  Cardiovascular:  Carotids obscured by breath sounds.

IMPRESSION:  The patient is a (XX)-year-old gentleman with prior brain insult, now with traumatic subarachnoid hemorrhage and subdural hematoma in the right frontal region and left cerebral convexity.  There is significant subcortical white matter disease in this patient.  It is unknown as to whether or not this patient had prior cerebral cortex stroke or a lacunar stroke, but it sounds by report of the head CT that he must have had a pure motor hemiparesis in the past.

Current level of functioning, prior to admission, is really not detailed in terms of cognitive status.  We do not know much about his habits, so we are not certain as to clear prognosis in this case.  Clearly, there will be no change in his hemiplegia.  Clearly, he will have a period of confusion and poor arousal, but the duration of that is unknown to us at this time, and as much as his subdural collection was relatively mild, it is difficult to be certain as to how much cognitive recovery he will have.  Clearly, there is a multi-infarct state in this patient, premorbidly, so more information needs to be known about how bad or good his cognitive function was prior to this fall.

Currently, he is not on any medication that would cognitively negatively impact, and except for the Lopressor, the Dilantin should not negatively impact, and cognitively, it was not necessary since the patient is at no risk for seizure.  We would go ahead and taper that 500 mg every three or four days till he is off.  In addition, we will check a Dilantin level on this patient to make sure he does not have Dilantin toxicity at a fairly high dose of Dilantin.  The Dilantin-free level was not available, but it appears that he was quite subtherapeutic at 3.5 on today’s laboratory evaluation.  Albumin, however, is very low at 2.4.

RECOMMENDATIONS:
1.  Taper the Dilantin as he is doing.  We would not pursue a free Dilantin in this patient, as it will become obsolete.
2.  Agree with the plan to switch the patient to Coumadin for his DVT, as he is safe to anticoagulate generally at 21 days status post bleed.
3.  We would try to get more information about how severely impaired this patient was, cognitively, prior to this.
4.  We will obtain his head CTs to review.
5.  We would start the patient on folic acid 1 mg daily and review his head CTs and give further information about prognosis.

We will continue to follow him.  We have no other therapeutic interventions at this time, but we believe his prognosis to return to the prior level of function is guarded.