DATE OF OPERATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Right-sided subdural hematoma.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed male with a history of a right-sided stroke and left-sided weakness. He presented with a complaint of headache and dizziness after a fall yesterday. CT scan of the head was performed that showed evidence of a right-sided acute subdural hematoma for which we were called for neurosurgical evaluation. The patient denied any new weakness or any numbness. The patient, of note, did present to the hospital one week prior with a complaint of vertigo and CT at that time apparently was unremarkable for hemorrhage.
PAST MEDICAL HISTORY: Significant for dyslipidemia, hypertension, hypothyroidism, and stroke.
PAST SURGICAL HISTORY: Significant for inguinal hernia repair, cholecystectomy, and knee surgery.
HOME MEDICATIONS: Include Lasix, potassium chloride, Lexapro, Lipitor, Synthroid, allopurinol, aspirin, Proscar, Antivert, and Flomax.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient denies tobacco or alcohol use. He lives with his wife.
FAMILY HISTORY: Unremarkable for history of intracranial pathology.
REVIEW OF SYSTEMS: All 14-point review of systems was discussed with the patient, significant for those things mentioned above and recent dizziness over the past couple of weeks.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4 degrees Fahrenheit, pulse 74, respirations 18, blood pressure 136/78, and O2 saturation on room air 98%.
GENERAL: The patient is a pleasant male. He is sitting on bed. He does not appear to be in any acute distress.
HEENT: The patient’s head is normocephalic. He has a small laceration over the vertex of his scalp with minimal underlying hematoma. There is no palpable deformity underneath it. Sclerae are noninjected and nonicteric. His oropharynx is clear. He has good speech. He has normal dentition.
NECK: The patient’s neck is supple with good range of motion. There is no Lhermitte or Spurling sign. There is no thyromegaly. No JVD. He has normal carotid pulsations.
HEART: Auscultation of the patient’s heart does reveal evidence of perhaps a grade 3 systolic ejection murmur. There are no gallops or rubs. He has normal S1 and S2 sounds.
LUNGS: Clear to auscultation bilaterally. There is no rhonchi, wheeze, or rale.
ABDOMEN: The patient’s abdomen is soft, nontender, and nondistended. He has normal bowel sounds.
EXTREMITIES: There is no clubbing, cyanosis, or edema. He has good pulses throughout.
NEUROLOGIC: The patient is awake, alert, and oriented x3. He has clear speech. He has normal mentation. His pupils are 3 mm, trace reactive bilaterally. Funduscopic exam reveals no evidence of papilledema. Extraocular movements are intact. His visual fields appear full. He does have a trace amount of nasolabial flattening on the left. His facial movement otherwise is symmetric. He has slightly decreased hearing, but this is symmetric bilaterally. His palate is upgoing. His tongue protrudes in the midline. He has normal shoulder shrug. His strength reveals a trace amount of left upper extremity drift and perhaps a minimal amount of weakness diffusely in the left upper extremity. His left lower extremity strength is 4+ to 5-/5; this is all old according to the patient. He has normal sensation, light touch, and pinprick throughout. He has 5/5 strength on the right. His reflexes are 2/2 at the biceps, triceps, and patellae bilaterally. His toes are downgoing on the right and they are equivocal on the left. There is no Hoffmann sign.
LABORATORY DATA: Sodium 137, potassium 4.3, BUN 46, creatinine 1.6, white count 4500, hematocrit 35.4, and platelets 136,000. PT 14.6, PTT 33.8, and INR 1.17.
DIAGNOSTIC DATA: We reviewed the patient’s CT scan of head, which showed evidence of a 1 cm thick right acute frontal, temporal, parietal subdural hematoma, and 3 mm of right to left shift. He has open cisterns. His ventricles are open. There is no evidence of herniation. No intraparenchymal lesions are seen.
IMPRESSION AND PLAN: The patient is a (XX)-year-old male with a history of a previous stroke and left-sided weakness. He now has a right-sided subdural after a fall. His exam appears stable. We had a discussion with his wife, who told us that the patient does indeed have a history of left-sided weakness. We suspect this is his baseline, however, we did explain to her our concerns stating that a subdural hematoma on the right side would cause similar symptoms, which she understands at this time. Both she and her husband are in agreement that we will continue to monitor this very closely. If he shows any evidence of worsening left-sided weakness or if his subdural hematoma increases in size with repeat imaging, we will recommend a right-sided craniotomy to evacuate the hematoma. If, however, his symptoms remain stable and the hemorrhage does not increase in size, we will continue to manage him medically. He should be admitted to the neurologic intensive care unit. He should undergo repeat head CT in the morning and his aspirin should be held. He should be started on Dilantin for seizure prophylaxis. We should be called if his neurologic exam worsens. His blood pressures should be kept at 160.
Thank you, Dr. John Doe, for allowing me to participate in his care.
