DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTANT: Jane Doe, MD
REASON FOR CONSULTATION: TIA versus stroke.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of hypertension and atrial fibrillation with permanent pacemaker, who presented to the ER complaining of acute left-sided weakness and numbness 1 day prior to admission. The patient reports that she woke up on Tuesday morning with left-sided weakness and numbness. She presented to the ER about 24 hours later for evaluation. The patient reported at that time that her left side was weak. She also had some slurred speech. Admission note from the ER stated that the patient said that her symptoms have resolved, but upon interview, at this time, she states that the symptoms actually have not completely resolved. The patient has a history of chronic atrial fibrillation and is on Coumadin, and her INR on presentation was therapeutic at 2.6.
PAST MEDICAL HISTORY: Hypertension, atrial fibrillation, status post permanent pacemaker placement, history of gastrointestinal polyps, and history of Helicobacter pylori infection.
PAST SURGICAL HISTORY: Cholecystectomy; hysterectomy; right breast tumor removal, which was benign, and pacemaker placement in the past.
MEDICATIONS: As an outpatient, Coumadin, Cozaar, digoxin, and atenolol.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies any drugs, alcohol or tobacco.
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable.
HEART: S1 and S2, paced.
NECK: No bruits.
NEUROLOGIC: Mental status: The patient is awake, alert, and oriented x3. Speech is fluent. Good comprehension. Cranial Nerves: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Visual fields are full. Face is symmetric. Tongue is midline. Palate is symmetric. Motor: 5/5 in the right and 4+/5 in the left with some apparent give-way weakness. Of note, there is no pronator drift present in the upper extremity. Good tone. No tremors noted. Reflexes are 1+ in right upper extremity, 2+ in left upper extremity, 1+ at the knees bilaterally, and 1+ at the ankles bilaterally. Plantars are downgoing bilaterally. Sensory: Decreased pinprick in the left face, arm, and leg. Decreased vibration on the left. Coordination is intact, finger-to-nose, with a mild intention tremor, but no ataxia.
LABORATORY AND DIAGNOSTIC DATA: CT of the brain done was negative for acute event. Repeat CT of the brain done 24 hours later was also negative. INR was 2.69 on admission. Chest x-ray was negative.
ASSESSMENT:
1. Left-sided numbness and weakness. The patient's main complaint consists of left-sided numbness of the face, arm, and leg. This could possibly be consistent with a thalamic lacunar stroke. Her weakness appears to be secondary to give-way rather than actual weakness. I did not recommend repeating CT of the brain any further as the second CT was done 72 hours after the event, which should show an acute lesion. I recommend checking a lipid profile. I agree with baby aspirin.
2. Peripheral neuropathy. Not mentioned above. The patient complains of burning and tingling of her feet, started about 2 months ago. Will send workup for neuropathy.
PLAN:
1. Physical therapy/occupational therapy evaluation.
2. Agree with aspirin therapy.
3. Will send neuropathy workup.
4. Will start gabapentin 200 mg p.o. q.h.s. for neuropathic symptoms.
5. EMG/nerve conduction studies as an outpatient.
Thank you, Dr. Doe, for this consult. We will follow along with you.
