DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Complete left upper and lower extremity flaccid paralysis.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old gentleman. Most of the history is obtained per EMR due to language barrier. Neurosurgery was consulted because of the concerning finding on CT scan of a left 1 cm frontotemporoparietal subdural hematoma. The patient presents tonight with the finding of a complete left upper and lower extremity flaccid paralysis. Per his son, the patient was at home when all of a sudden this occurred. It was acute in onset and happened approximately three hours ago. Since that time, it has failed to improve. The patient does not complain of any pain. He does not seem basically distressed by his inability to move his left side. However, given his symptoms, the son brought him here for definitive care.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Unknown.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: Unknown.
ALLERGIES: Unknown.
MEDICATIONS: The son says that he does take a hypertensive medication; although, he is unable to tell us which one.
REVIEW OF SYSTEMS: A 10-point review of systems is otherwise negative.
PHYSICAL EXAMINATION: The patient is an elderly gentleman who appears his stated age. At this time, he is awake and oriented x3. Speech is intact; although, naming and repetition could not be adequately evaluated. On cranial nerve examination, the pupils are round and reactive, and extraocular movements are intact. The face exhibits that there is a slight left facial droop. The patient is unable to tell us if he has equal sensation in the V1, V2 and V3 distributions. When asked to show us his teeth, he has a pronounced facial droop on the left side. His hearing seems to be intact. He was unable to raise his shoulder on the left side. We were not able to evaluate whether his tongue deviated to one side or the other. On motor and sensory exam, the patient exhibited full strength in all muscle groups in the upper and lower extremity on the right side. On the left side, however, the patient has 0/5 movement in his arm or in his leg in all muscle groups. Reflexes are +2 in the right side. Babinski’s reflex was deferred.
LABORATORY WORK: Pending.
MEDICAL IMAGING: A CT scan of the brain reveals that there is a left 1 cm frontotemporoparietal subdural hematoma, which is exhibiting some mass effect and compression of brain.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman who presents with approximately three hours of acute left upper and lower extremity flaccid paralysis. At this time, it would appear that this patient is not a neurosurgical patient. You would expect for a left-sided frontotemporoparietal subdural hematoma causing significant brain compression. The patient does exhibit right upper and lower extremity weakness. However, in this case, the neurology does not fit. He is weak on his left side. Therefore, we think that this could possibly be related to a stroke and recommend that Neurology be consulted on an urgent basis for further evaluation. Once again, the patient has no neurosurgical issues at this time.
