DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation and management of abnormal MRI of the cervical spine.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American female who drove herself to the emergency department yesterday after left arm and left leg numbness. The patient reported that when she got up yesterday morning, she just did not feel right. The patient drove to work and on the way her left arm felt numb and heavy from the shoulder to fingertips, according to her. These symptoms lasted about 30 minutes. The patient’s left leg also became numb from her foot up to her knee. At that time, she drove herself to the emergency department. She denies any associated weakness. The symptoms resolved yesterday afternoon and she feels back to her baseline now. She denies any difficulty with speech or swallowing, headaches, chest pain, shortness of breath, visual disturbances, gait difficulties, or other associated symptoms. The patient did have an episode of dizziness many months ago. She was also worked up by Neurology and ENT for this dizziness, and those workups were unremarkable. The patient also reports some intermittent right facial numbness after a fall she sustained 4 years ago. She also has occasional neck pain for the past 2 or 3 weeks, which has now resolved after using alternating heat and ice.
PAST MEDICAL HISTORY: Right femoral fracture, status post internal fixation, as a result of a motor vehicle accident, right facial numbness, status post fall. Otherwise, past medical history is noncontributory.
MEDICATIONS: None.
ALLERGIES: IV DYE.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies alcohol, tobacco, or illicit drug use. She is divorced.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 104/70, pulse 86, respirations 18, and temperature 98.6.
GENERAL: This is a moderately obese (XX)-year-old woman, sitting up in the chair, in no acute distress. She is alert and oriented to person, place, and time.
NEUROLOGIC: Her speech is fluent. Language is intact. Attention, memory, and concentration are normal at the bedside examination. Cranial Nerve Evaluation: Pupils are equal and reactive, 3 mm bilaterally and brisk. Extraocular movements are intact. Visual fields are full to confrontation, intact. Corneal reflex is intact. Hearing is present to finger rub. Tongue is midline with good palate elevation. No facial asymmetry noted. Motor examination reveals power, 5/5, in all extremities with normal bulk and tone. Fine motor coordination is intact with finger-to-nose testing. She has good sensation in all extremities laterally and medially to pinprick and temperature. Deep tendon reflexes are symmetric. Babinski is negative. There is no pronator drift. Her gait is with significant right limp due to the right femoral fracture she sustained from a motor vehicle accident.
LABORATORY DATA: CBC and CMP are unremarkable. Triglycerides 56, total cholesterol 174, HDL 52, LDL 110. Cardiac enzymes, first 2 sets were negative.
DIAGNOSTIC STUDIES: CT of the brain reveals no acute abnormality. MRI of the brain reveals partially empty sella, mild right cerebellar tonsillar ectopia of the cerebellar tonsils, at the lower limits of normal. Intracranial ischemia not appreciated. MRI of the cervical spine revealed mild C6-7 stenosis with diffuse posterior protrusion and left foraminal spur. Shallow diffuse C5-6 posterior protrusion with asymmetric left foraminal narrowing due to uncinate process spurring, multilevel left facet arthropathy, asymmetric left C2-3 foraminal narrowing. Cerebellar tonsillar herniation through the foramen magnum 7.6 mm on the right and 4.4 mm on the left.
IMPRESSION: Left arm and left leg paresthesias, which have now resolved after approximately 10 hours. At this time, her symptoms are unlikely an acute neurological event.
RECOMMENDATIONS: Cardiac workup is in progress, and given her possible cardiac abnormality, this might be causing her symptoms. If her paresthesias do recur, we can see the patient as an outpatient for EMG and nerve conduction studies.
Thank you, Dr. Doe, for including us in the care of this patient. We will follow along with you.
