DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Headache and diplopia.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presented to the emergency department yesterday with headache and chest pain. Her chest pain has actually been going on for the past month but had gotten worse over the past three to four days with associated nausea. She reports that her headaches started Friday, four days ago, while she was eating dinner and watching TV, rather acutely. She describes it as mostly right-sided, occipital, constant, shooting, pulsing to her right jaw, neck, and behind her ear. Since her hospitalization, it has also started shooting to her right clavicle, and she also complains of left leg numbness and weakness. The patient does have a history of migraine headaches, which started in her late teens, at which time she got about four migraines per year. Her typical migraine then was debilitating and more frontal; the top of her head was associated with photophobia, sonophobia, and nausea. Imitrex worked for those headaches. This headache is different in intensity and location. She denies any sensitivity to light or sound and only complains of nausea and dry heaves. She actually denies any diplopia and describes her visual disturbance as blurred vision in her right eye, greater than the left. She denies any facial numbness or weakness, difficulty with speech, swallowing, unsteady gait, and shortness of breath.
PAST MEDICAL HISTORY: Appendectomy, tonsillectomy, and laparoscopy.
MEDICATION: Valium p.r.n.
ALLERGIES: NKDA.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She smokes about eight cigarettes a day, most on the weekends. She drinks red wine mostly on the weekends. She is married with two children.
REVIEW OF SYSTEMS: As above, otherwise please refer to the history and physical.
PHYSICAL EXAMINATION: Blood pressure 122/78, pulse 60, respirations 18, and temperature 98.4 degrees. This is a pleasant well-developed, well-nourished (XX)-year-old woman lying in bed, in no acute distress. She is alert and oriented to person, place, and time. Speech is fluent. Language is intact. Attention, memory, and concentration are normal. On cranial nerve evaluation, pupils are equal and reactive, 4-2 mm bilaterally and brisk. Visual fields are full. No nystagmus noted. Corneal reflexes are intact. Accommodation is intact. Hearing is present to finger rub. Tongue is midline with good palate elevation. Sensory exam revealed decreased sensation to pinprick in her left lower extremity, otherwise good sensation throughout. Motor examination revealed power 4+/5 in her left lower extremity, otherwise full strength throughout proximally and distally. Fine motor coordination is intact with finger-to-nose and heel-to-shin testing done bilaterally. Gait was steady and coordinated. Romberg is negative.
LABORATORY AND DIAGNOSTIC DATA: Yesterday, CBC and CMP were unremarkable. Cardiac enzymes were negative x2. MRI of the brain was unremarkable. CT of the brain was unremarkable. MRA of the head and neck was unremarkable.
IMPRESSION: Headache, likely migrainous with unremarkable neurological workup so far. The patient’s headache could be cardiac related and the workup is in progress.
RECOMMENDATIONS: At this time, would finish cardiac workup regarding her headache but only recommend pain management at this time.
Thank you, Dr. Doe, for referring this patient to us. We will follow the patient along with you and make further recommendation as appropriate.
