DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: New onset seizure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed man who was admitted through the emergency room yesterday after he experienced an episode of loss of consciousness at home. The patient was working on his computer when he started to feel strain in his right hand. He turned the computer off and, as he was getting up, his right arm started to involuntarily shake. The patient was unable to control his right arm and, as he grabbed his right arm tightly, he fell and lost consciousness. The patient was unresponsive for a few minutes. Per his son, who witnessed the episode, he was drooling and frothing from the mouth. Eyes were closed. There was no tongue bite or urinary incontinence. Paramedics were called. Upon arrival of the paramedics, the patient was uncooperative and confused. He gradually regained consciousness but did not gain full awareness until he was in the emergency room. The patient only has partial recollection of the events. Initial blood pressure, as documented by paramedics, was 210/106. The patient has not been taking his blood pressure medications regularly.
PAST MEDICAL HISTORY: He has a significant history of stroke with residual mild expressive aphasia. The patient has a history of coronary artery disease and is status post CABG and multiple angioplasties. He also has a history of aortic valve replacement with St. Jude’s valve. He has a history of hypertension, diabetes mellitus, peripheral vascular disease, and is status post multiple angioplasties of the lower extremities.
MEDICATIONS: His current medications include Glucovance, Lopressor, Coumadin, Zocor, Hytrin, Pepcid, Allegra, Zoloft, Nasonex, Endocet, and he is on Neurontin 300 mg t.i.d. for neuropathic pain.
SOCIAL HISTORY: The patient lives at home with his wife.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Please see above for details. No recent fever, chills, nausea, vomiting, chest pain, palpitations, or urinary or bowel incontinence.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed and well-nourished man, in no apparent distress.
VITAL SIGNS: Blood pressure is 158/68, pulse is 78 per minute, in sinus rhythm with bigeminy. The patient is afebrile.
HEENT: Head is atraumatic.
NECK: Supple. There are no carotid bruits.
CHEST: Clear.
ABDOMEN: Soft. There is no peripheral edema.
NEUROLOGICAL EXAMINATION: The patient is alert and oriented. Speech is mildly subfluent with occasional paraphasic errors. Comprehension is good. The patient was able to repeat simple sentences. He was able to name properly. Cranial Nerves: Pupils are equal and reactive. Visual fields are full. Extraocular movements are intact. There is no nystagmus. Facial sensations are decreased on the right side. There is no facial asymmetry. Tongue is midline. Motor strength is 5/5 throughout. Tests of coordination are normal. Deep tendon reflexes are 1+ in the upper extremities and at knees and absent at ankles. Babinski sign is not present. Sensations are decreased to pinprick throughout on the right side. There is also decreased pinprick sensation in the feet distally. Vibratory sensations are decreased at the toes bilaterally.
CT scan of the brain in the emergency room revealed old left MCA distribution infarct. There is no new infarct or bleed. INR was 2.1 on admission.
IMPRESSION:
1. New onset seizure disorder, partial onset, with a secondary generalization. Likely etiology is poststroke seizure disorder. Hypotension may have contributed. Although not typical, hypotensive encephalopathy cannot be entirely ruled out. Also, rule out recurrent cerebral infarct; although, the patient’s examination at present is at his baseline.
2. History of recurrent stroke with the residual mild expressive aphasia.
3. Multiple medical problems as outlined.
RECOMMENDATIONS: We agree with doing EEG and MRI scan of the brain. We will review test results when completed. The patient will most likely need to be started on long-term anticonvulsant treatment. He is at present on a small dose of Neurontin for pain. This dose is not optimal for seizure prevention and Neurontin is not an optimal medication for seizure prevention as a monotherapy. Trileptal or Tegretol will be preferred, as these medicines would not interfere with the anticoagulation and may also help neuropathic pain.
Thank you for requesting neurological evaluation of your patient. We will follow the patient and discuss further.
