DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: To evaluate the patient’s current cognitive and emotional functioning following central nervous system compromise secondary to leukemia diagnosis.
PRESENTING DIAGNOSIS: Promyelocytic acute myelogenous leukemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic gentleman, right handed, who has a new diagnosis of promyelocytic acute myelogenous leukemia. The patient has a history of repeated deep vein thrombosis and has been on Coumadin over the past six years with one period of being off of the Coumadin. The patient initially presented to the hospital with symptoms of coughing and fever and also had notable bruising that initially was attributed to the Coumadin therapy. The patient was discovered to have pancytopenia, and last month, the patient complained of headache with nausea. A noncontrast CT scan of the brain revealed a left temporal lobe intracerebral hemorrhage, approximately 2 cm in size, with mild intraventricular hemorrhaging as well. The patient was placed in the intensive care unit and was seen by multiple specialties. The patient is also being followed by Hematology-Oncology secondary to the leukemia diagnosis. Prior to this, the patient was relatively healthy and functioning. This consultation was provided secondary to potential neurocognitive findings from the intracerebral hemorrhage as well as evaluating his emotional adjustment secondary to the new onset of leukemia.
PAST MEDICAL HISTORY: Recurrent deep vein thrombosis resulting in Coumadin therapy.
PAST SURGICAL HISTORY: Unremarkable.
FAMILY MEDICAL HISTORY: Noncontributory.
ALLERGIES: NKDA.
MEDICATIONS: At the time of the consultation included MS Contin, Senokot-S, lactulose, Klonopin, Cymbalta, Catapres, Keppra, Vesanoid, Norvasc, metoprolol tartrate, Flonase, and Deep Sea Nasal Spray. The patient is also receiving chemotherapy.
PAST PSYCHIATRIC HISTORY: Unremarkable.
SOCIAL HISTORY: The patient is divorced. Educationally, the patient has a high school degree and some college. Occupationally, the patient was working with a company that is involved in event management. The job requires a fair amount of travel both in and out of the country. One of the difficulties has been the patient has been feeling run down but attributed the initial symptoms to traveling. The patient has been in this occupation for approximately a year. The patient has a steady employment history otherwise. The patient’s parents are also present during this evaluation.
SUBSTANCE USE HISTORY: Essentially negative.
EXAMINATION RESULTS: The patient was partially alert but was oriented when he became more fully alert during the process of the clinical interview. One of the intervening factors in the clinical interview was that the patient was having significant abdominal and GI pain secondary to lack of bowel movement, which appeared to be secondary to the current use of pain medications. The patient was having significant pain, so his parents provided much of the information during this interview. When the patient was able to cooperate, he was fully alert, cooperative, and oriented. Also of note, the patient has a significant blindness at this time. This is expected to resolve at least partially, if not fully, and this is secondary to hemorrhaging, as per our understanding.
With regard to sensory and motor functions, the patient is demonstrating weakness overall. However, sensory and motor functions were grossly intact. The patient was able to ambulate with standby assistance. The patient again was weak but was able to have good sitting balance and was able to move freely in bed.
With regard to his current cognitive functions, the patient demonstrated excellent remote recall of information leading to the hospitalization. The patient has been keeping up with many details though periodic forgetfulness has been noted. Higher cognitive functions, including executive functions, also appeared to be working quite well. Language skills were grossly intact. Higher centers such as problem solving and learning were also grossly adequate for purposes of the evaluation. The patient is being monitored carefully by nursing. The patient’s parents were also present and assisting. Cognitive testing would be indicated; however, not at this time. Intervening factors included his current in and out of his fatigue secondary to the current treatment regimen, as well as his current dealings with leukemia. The patient has also had significant pain medications, which seemed to be causing him to fluctuate to some degree. Laboratories values appeared adequate, however. Cognitive testing would be indicated, either just prior to discharge from the hospital or as an outpatient followup when the patient is considered medically stable. At this time, we will continue to monitor his progress and will determine the appropriateness of testing just prior to discharge or at discharge.
Thought process and thought content; however, were mood congruent without evidence of hallucinations or delusions. However, according to the patient’s family, he did have hallucination experiences in the ICU. The patient has had auditory, visual as well as olfactory hallucination experiences. Delusional thought process was not evident, however.
With regard to behavioral activity and safety, the patient is unsafe secondary to being weak, but the difficulties with safety is not related to his current cognitive functions based on what was observed at this time. Standby assist is recommended.
With regard to current affect and mood, the patient’s affective expressions were very limited, that when the patient was fully awake and alert and was able to interact appropriately in the examination, that his affect was broad. The patient’s overall mood state was one consistent with dysthymic quality. The patient has had significant adjustment secondary to a significant change in lifestyle because of the diagnosis of leukemia as well as loss of his vision. The adjustment appears to be in reaction to the current medical findings. Vegetative features were evaluated. The patient is resting most times, again secondary to fatigue issues. Appetite cannot be evaluated at this time. Sleep is also different than what it was prior to hospitalization, again secondary to current medical findings and treatment. There were no issues related to suicidal thought, intent or plan. No homicidal ideation, intent or plan. Again, depressed mood was secondary to current medical issues.
IMPRESSION: At this time, neuropsychology impression is consistent with mixed presentation. The patient needs to have cognitive testing to determine the extent of the injury to the temporal lobe, but at this time, this did not appear to be appropriate given the current medical issues. This is deferred at this time. The second finding is that there is an adjustment reaction secondary to his current medical profile and condition. It is likely that this will be prolonged based on how he does with the overall treatment. In talking with the parents, they have indicated the same. Also, we did talk extensively about issues related to work and living at the time of discharge with either independence or supervision level.
AXIS I:
1. Rule out cognitive disorder, not otherwise specified.
2. Depressive disorder, not otherwise specified, secondary to current medical condition.
Axis II: Deferred.
Axis III: Promyelocytic acute myelogenous leukemia with blindness.
Axis IV: Current psychosocial stressors include occupational dysfunction at this time; stress within primary support system secondary to current diagnosis; also visual blindness.
Axis V: Current Global Assessment of Functioning equals approximately 60, past year Global Assessment of Functioning equaled approximately 90 or better.
RECOMMENDATIONS: At this time, neuropsychology followup would be indicated on a p.r.n. basis secondary to adjustment issues related to current medical findings. We have provided extensive education to both the patient and family with regard to his current level of neurocognitive function as well as educating them with regard to temporal lobe defects secondary to intracerebral hemorrhaging. The patient would benefit from neurocognitive testing prior to discharge or else at the time of discharge, and this has already been arranged with the patient’s family.
