DATE OF ADMISSION: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic male smoker, 3 pack per day x30 plus years, right-hand dominant with known heart disease status post CABG, hypertension, dyslipidemia, and renal insufficiency was admitted through the emergency department with symptoms of mental confusion and poor orientation along with worsening ataxia. The patient was brought in by his wife who reported that he is just not right. The patient agreed with this assessment. No localizing neurologic deficits could be identified in the emergency department. The patient’s initial head CT scan showed no signs of acute infarct or hemorrhage, only atrophy. His laboratory studies were remarkable for chronic renal insufficiency with elevated BUN and creatinine. His blood gas on admission was normal with
The patient’s initial head CT scan showed no signs of acute infarct or hemorrhage, only atrophy. His laboratory studies were remarkable for chronic renal insufficiency with elevated BUN and creatinine. His blood gas on admission was normal with O2 saturation of 95%.
The patient was not well oriented to place or time. He could not identify the correct year, had difficulty identifying which hospital he was in. The patient could only identify the correct hospital when given a choice of three different hospitals, and even then, he initially misidentified the hospital without finding the right answer. The patient was only able to identify me as his physician. When asked to take a guess at correct responses, the patient often responds, “I just don’t know.” The patient also acknowledges some worsening ataxia over the past few days. He denies any fever, chills, nausea, vomiting or change in appetite. The patient denies any symptoms of headache.
PAST MEDICAL HISTORY: History of heart disease, status post coronary artery bypass graft; history of hypertension; history of gastroesophageal reflux disease; tobacco abuse/dependency, dyslipidemia; moderate trunk obesity; history of depression; history of chronic anxiety; history of vocal hoarseness; history of calcified granuloma, left lower lobe, documented on chest CT; history of claudication secondary to peripheral vascular disease with exertion.
SOCIAL HISTORY: The patient is married. He acknowledges a long history of tobacco use. He acknowledges occasional use of alcohol.
FAMILY HISTORY: The patient’s mother died at age 78. His father died at age 40 in an accident. The patient has three sisters and two brothers, all in apparent good health.
REVIEW OF SYSTEMS: Negative for weight changes, nausea, vomiting, headache, blurred vision. Positive for recent ataxia and generalized lower extremity weakness. Positive for change in bowel habits over the last year.
OBJECTIVE:
VITAL SIGNS: Afebrile. Pulse 92, respirations 20, and blood pressure 144/78.
GENERAL: The patient is a (XX)-year-old Hispanic man, well nourished, well developed, moderately overweight, alert, awake, in no acute distress but appearing somewhat confused.
HEENT: Within normal limits. Eyes: Extraocular movements intact. Pupils are round and equally reactive to light and accommodation.
NECK: Supple with normal range of motion. No carotid thrills or bruits. No thyromegaly or masses noted.
LYMPH: No palpable lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. Normal S1, S2 without murmurs.
ABDOMEN: Protuberant, soft, nontender. No organomegaly, masses, rebound tenderness.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: The patient is unable to hold hands level with eyes closed, elevation in left upper extremity with hands extended. The patient is unable to stand erect with eyes closed and feet together. Slight right lower facial droop. Slight tongue deviation to the left with protrusion. Extraocular movements are intact. Pupils are equally round and reactive to light and accommodation. Babinski is not tested.
SKIN: Warm and dry without lesions.
ASSESSMENT:
1. New onset symptoms of mental confusion and poor orientation.
2. History of hypertension.
3. History of heart disease.
4. History of tobacco abuse.
PLAN:
1. Schedule brain MRI and MRA today.
2. Consult Neurology.
3. Labs: Check sedimentation rate, C-reactive protein, RPR, serum thiamine levels.
4. Plan LP for CSF analysis if MRI normal.
