DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Assistance with management of medications.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old left-handed Hispanic gentleman with a past medical history significant for relapsing-remitting multiple sclerosis, seizure disorder, cognitive impairment and central sleep apnea, who was admitted to the hospital with pneumonia. This morning, apparently, the patient took his anticonvulsants from the supply that he had in his room. The hospital-administered anticonvulsants were then given to him. As a result, it appears that he took a double dose of anticonvulsants this morning. A neurology consultation was requested to assist with the management of his medications.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: Significant for ear surgery.
ALLERGIES: No known medication allergies.
MEDICATIONS: Betaseron, amantadine, Dilantin, theophylline, Keppra 1500 mg p.o. b.i.d., prenatal vitamins and Ritalin.
SOCIAL HISTORY: The patient denies any use of tobacco. He drinks alcohol occasionally.
FAMILY HISTORY: Significant for multiple sclerosis.
REVIEW OF SYSTEMS: Could not be accurately obtained from this cognitively impaired gentleman.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished, Hispanic gentleman, in no apparent distress.
VITAL SIGNS: Temperature 98.6, pulse 114 and blood pressure 128/82.
NECK: Supple.
NEUROLOGIC: The patient is alert and oriented to person, place and time. Speech is clear and language is fluent with normal naming, comprehension and vocabulary. The examination of the cranial nerves revealed full visual fields, intact extraocular movements and equal, round and reactive pupils. Slight nystagmus was noted with left lateral gaze. The fundi were not clearly seen. The facial sensation was full and the face was symmetric. The patient’s hearing was diminished bilaterally. The palate rose symmetrically. Shoulder shrug was symmetric, and the tongue protruded in the midline. On motor examination, the bulk and tone were normal. The motor strength was 5/5 throughout without tremor or drift. Deep tendon reflexes were 2+ throughout with the exception of ankle jerks, which were absent bilaterally. The plantar responses were flexor bilaterally. Sensations were intact to light touch, proprioception and vibration. Coordination was intact to finger-to-nose and heel-to-shin testing. Gait was not evaluated.
IMPRESSION:
1. Multiple sclerosis.
2. Seizure disorder.
3. Accidental administration of double dose of anticonvulsant medicines.
RECOMMENDATIONS:
1. Check Dilantin and Keppra levels now and tomorrow morning.
2. Hold the night’s Dilantin and Keppra doses.
3. Resume regular anticonvulsant administration schedule tomorrow.
4. We will follow with you.
Thank you, Dr. Doe, for asking us to see this patient in consultation and for allowing us to participate in his medical care.
