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NEUROLOGICAL SYSTEM - CONSULTATION REPORT
PATIENT NAME: Robert BROWN
AGE: 74
SEX: Male
DOB: July 5
DATE OF CONSULTATION: April 15
CONSULTING PHYSICIAN: Martin Lewis, MD, Neurology
REASON FOR CONSULTATION: Assessment of cognitive changes and testing.
HISTORY: The patient presented a few days ago with a marked change in identified by his family members and care staff. The reports describe two episodes of the patient presenting a somewhat confused state, instability with a “holding of the temples” and a report of blurring vision. The patient was also observed holding on to walls and furniture to walk around. This seems to have been two transient episodes and has not recurred since. Prior to that, he had maintained excellent cognitive abilities with full lingual ability, no signs of aphasia, or loss of consciousness. The cognitive decline noticed was not of gradual onset but rather an acute change within hours to a day. The time span is unclear as the patient lives alone and there was a time lapse between a family visit and the arrival of a personal care assistant.
The patient is a good historian to questioning and does admit to some recent occasional headaches and vision. These are new to him as he reports never having “had a headache” in his “whole life”. He reports that the blurring is not constant but only seems to occur when he turns his head to right or left suddenly. There is a “tilting sensation” like he will fall but this clears when he brings his head back to center. He has no history of epilepsy or seizure disorders. No history of TM or ear trauma.
PHYSICAL EXAMINATION: HEENT: Head is normocephalic. EYES: PERRLA. EARS: Auditory exam reveals intact TMs bilaterally. No erythema. The nose and throat exam is unremarkable. NECK: JVD appears normal. VITAL SIGNS: Blood pressure is 132/86 with no previous history of . Pulse is 83 and resp. 22 but the patient does admit to feeling anxious during the assessment. Temperature 37C.
NEURO: Orientation and language are normal. Extremity strength testing show some minimal weakness in the right upper. Reflexes are normal. Toes are bilaterally. Has difficulty with heel-and toe-walk and is unable to tandem walk. The gait is alternately normal and minimally spastic.
IMPRESSION: What appears to be a transient or acute cognitive change with altered awareness, headache and cephalo-positional blurring of vision. There is some change, although minimal and not clinically diagnostic, as evidenced by the slight changes in gait during testing but it does not remain consistently. This is puzzling.
PLAN: It is still not clear to me what these spells are. Some of the neurological possibilities to be considered are TIA, , brain and spinal cord tumors, inflammation, infection, vascular irregularities, and some neurodegenerative disorders. I have ordered a stat cerebral , electroencephalogram (EEG) and blood levels for CBC, chem panel. However, I feel we should also rule out the more common possibilities of pseudo-seizure, vertigo, and inner ear anomalies and am in the process of making these appropriate bookings.
I have booked a follow up with this patient in 10 days to review the results. He and his family have been advised to contact me immediately if he has another “spell” or to present to the ER where we can complete testing when the patient is .
Thank you for this most interesting referral. I will be in touch after I have reviewed the patient.
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Martin Lewis, MD, Neurology