DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hydrocephalus.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old woman. The patient over several weeks noticed intermittent episodes of progressive memory loss and confusion. The patient thinks that her short-term memory is more affected. Currently, she denies any confusion and thinks that her mentation is normal. She denies any headache. She denies any visual disturbances. She denies any nausea or vomiting. She does admit to somewhat unsteady and clumsy gait. There is no history of bowel or urinary incontinence. A CT of the brain is suggestive for communicating hydrocephalus.
PAST MEDICAL HISTORY: Remarkable for esophageal carcinoma and breast CA.
PAST SURGICAL HISTORY: She underwent an esophagectomy.
MEDICATIONS: Lipitor.
PHYSICAL EXAMINATION: Neurologic Examination: Overall nonfocal. The patient is awake and alert with a very pleasant affect. She is eloquent, and her speech is fluent. She is oriented x3. Her mentation appears to be normal. Cranial nerve examination II through XII normal. Pupils are equal and reactive to light and accommodation. Extraocular movements are intact. There is no nystagmus. The face is symmetric. Remaining cranial nerves are normal. Extraocular range of motion is normal. There is no nuchal rigidity. Motor strength is 5/5 throughout. There is no upper extremity drift. Her muscle tone is normal. Deep tendon reflexes are hypo to normoactive. There are no pathologic reflexes. There are no long tract signs. Sensory examination is intact to light touch and proprioception. Her gait is slightly wide based and shuffling. She has mild dyskinesia when trying to tandem gait.
DIAGNOSTIC DATA: A CT of the brain reveals enlarged lateral and third ventricle with transependymal edema.
ASSESSMENT AND PLAN: The patient’s presentation and radiologic abnormalities are consistent with communicating hydrocephalus. Currently, she is neurologically stable. We will obtain an MRI of the brain with and without contrast, especially in view of her previous history of breast and esophageal CA. Depending on the findings, she might benefit from intervention with shunting procedure.
