DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation and management of left leg weakness.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who has been treated for lower extremity weakness in the past post an AAA repair. The patient also has chronic pain management issues with low back pain, has had a previous workup for this. The patient was in chronic pain management physician’s office and was found to have left lower extremity quite cooler and with decreased pulses. The patient was advised to call Dr. John Doe who advised the patient to come to the emergency department. The patient’s wife is at bedside and wife and patient describe a progressive weakness in the left lower extremity that has gotten more difficult over the last month, and the patient is now having difficulty even ambulating with a walker short distances.
PAST MEDICAL HISTORY: Chronic low back pain, chronic left lower extremity weakness, diabetes, COPD, benign prostatic hypertrophy, history of alcoholism, coronary artery disease.
PAST SURGICAL HISTORY: Transurethral resection of the prostate, AAA repair, esophageal dilatation, and percutaneous coronary artery grafting.
ALLERGIES: MORPHINE.
CURRENT MEDICATIONS: Protonix 40 mg every day, cephalexin 500 mg every day, Restoril 15 mg at bedtime, Flomax 0.4 mg at bedtime, enalapril 5 mg b.i.d., Lopressor 25 mg b.i.d.
SOCIAL HISTORY: The patient lives with his wife and has remote alcohol and tobacco use. No drug use.
REVIEW OF SYSTEMS: The patient has had chronic back pain and left lower extremity weakness, but the patient is now having more difficulty with spasms and tone. The patient is unable to walk any distance and short distances are even getting more difficult. The patient is unable to ambulate without assistive devices. The patient denies any upper extremity weakness. The patient denies any difficulty with his eyesight. The patient denies any balance problems. The patient denies any headaches. The patient denies neck pain. The patient denies shortness of breath or chest pain. The patient denies any recent fevers or illnesses. For all other review of systems, refer to history and physical.
PHYSICAL EVALUATION:
VITAL SIGNS: Temperature is 97.6, pulse is 52, respirations 18, and blood pressure is 162/72.
GENERAL: This is a thin, Hispanic male.
HEART: S1, S2 normal. Pulses are present in all extremities. There is no cyanosis. Skin is warm. There are no carotid bruits.
LUNGS: Clear.
NEUROLOGIC: The patient is alert and oriented to person, place and time. Speech is fluent. Language is intact. Short-term and long-term memories appear adequate. Cranial Nerve Exam: The patient’s pupils are equal and reactive at 2 mm and brisk. EOMs intact. Visual fields are intact. Accommodation is intact. Corneal reflex is intact. The patient has a slight right nasolabial flattening. Tongue is midline with good palate elevation. Motor exam reveals bilateral upper extremities to be 5/5, the left lower extremity to be 2-1/2 out of 5 and the right lower extremity to be 4/5. The patient has upgoing toes, greater on the left than on the right. Has no clonus. Has increased spasticity in the left lower extremity. Deep tendon reflexes are +3 in both lower extremities and +2 in the upper extremities. The patient’s gait with walker is shuffled with a tendency to drag the left lower extremity and inability to bend at the knee in a standing position. Sensory exam reveals bilateral stocking distribution to mid calf to pinprick in both lower extremities and decreased proprioception in bilateral feet.
LABORATORY DATA: WBC 10.8, hemoglobin 12.4, hematocrit 37.8, and platelet count 192. Sodium 140, potassium 4.5, chloride 104, CO2 of 28, glucose 142, BUN 46, creatinine 1.6, and calcium 9.6. Liver functions are within normal limits.
IMPRESSION: Gradually progressive, left greater than right, lower extremity weakness suggestive of spasticity and upper motor lesion.
PLAN: We will do an MRI of the brain and C-spine. Will check B12 and RPR levels. Physical therapy to evaluate and treat.
