DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: This (XX)-year-old female is being seen in consultation for the evaluation of questionable stroke.
HISTORY OF PRESENT ILLNESS: The patient came to the emergency room where she was evaluated clinically and with a series of blood tests and a CT scan. She was discharged for an outpatient MRI of the brain. The MRI was unremarkable and only some age-appropriate changes were noted. We reviewed the MRI and also noted that the flow voids on the MRI were also unremarkable. The event that prompted her evaluation in the emergency room was primarily an amnestic event. She had driven from home to the grocery store to buy groceries but does not recall going to the grocery store and does not recall buying the groceries. She returned home, and her husband commented that she was behaving oddly. He invited her to sit down with him to watch a show that they usually watch, but she walked away from him. Two to three hours later, she returned to baseline and did not believe the events that her husband recited to her. She then started calling the grocery store to confirm that in fact she made it to the grocery store, which in fact she did without any incidents and returned home without any difficulties. She states that approximately 15 years ago, she was involved in a motor vehicle accident. Her car was clipped by a truck, and she seems to be forgetful about the details of that event. It is unclear if she actually hit her head at that time. She has not had any other neurological difficulties. She states that she is under significant stress because of a false positive reading on a mammogram recently, but this has been cleared, and she is doing generally better. There are no other neurological issues. The symptoms have not recurred, and she is back to her baseline functioning independently.
PAST MEDICAL HISTORY: Significant for hypertension and hypercholesterolemia.
CURRENT MEDICATIONS: Simvastatin, bisoprolol, aspirin, calcium supplement, vitamin C, Metamucil, vitamins and MetroGel.
SOCIAL HISTORY: The patient is married. She does not smoke and does not drink alcohol.
FAMILY HISTORY: The patient has six siblings. Father died of a cerebral aneurysm.
REVIEW OF SYSTEMS: Otherwise negative and noncontributory.
PHYSICAL EXAMINATION: Blood pressure is 162/90, pulse 66 and regular, respiratory rate 14, and pain scale is zero. Blood pressure was checked again, and it was noted to be at 140/80. There are no carotid audible bruits, and radial pulses are symmetric. Cardiac examination is unremarkable. She is sitting comfortably in a chair. She is well groomed with normal affect, conversant and appropriate with no dysarthria, aphasia, right-left confusion or finger agnosia. Cranial nerve examination reveals normal fundi and normal visual fields. Pupils are symmetric and reactive. Extraocular muscles are full without nystagmus. There is no facial weakness. Tongue is midline. Palate elevates symmetrically bilaterally. Hearing to bedside testing is normal Shoulder shrug is normal. Motor examination reveals no tremors or myoclonus or focal weakness. Cerebellar testing of cranial nerves is normal. Her gait is normal. Deep tendon reflexes are 1+ throughout, and toes are downgoing bilaterally.
ASSESSMENT AND RECOMMENDATIONS: The patient had an episode that is likely consistent with transient global amnesia. We recommended an EEG, but she declined. Her neurological examination is unremarkable. We encouraged the patient to keep us updated. We will be happy to see her in the future on an as-needed basis. Her blood pressure was initially elevated, but upon rechecking, the blood pressure appears to be lower than when she came in to the office, but this can be followed by her primary care physician. We explained to her that transient global amnesia is not an indication of transient ischemic attack or stroke, and generally, these events are of once in a lifetime. The event that occurred 15 years ago may have been associated with some head trauma related to a motor vehicle accident and not related to any other primary neurologic event.