DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Regarding aneurysm and recent intracranial hemorrhage.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed man who presented to the hospital after a syncopal episode. He was mowing his lawn. He developed a tired sensation in his neck. He felt lightheaded. He went down one knee to gather himself. He passed out and rolled over into the road where he was found by someone else. He thinks he was out for a couple of minutes. He awoke feeling confused and dazed. He had a similar, less severe episode in August of this year. This was also preceded by sensation of tiredness in his neck with subsequent lightheadedness and syncope. He states he had a big knot on his head at that time. He does not recall as to whether or not he had intracranial hemorrhage. He states that he occasionally gets lightheaded on arising and he has done so since his heart surgery about a year ago. He denies episodes of blurred or double vision or visual loss, extremity weakness or numbness, or difficulty speaking or understanding other people. He denies any history of previous stroke.
PAST MEDICAL HISTORY: Significant for coronary artery disease. He is status post coronary artery bypass grafting and mechanical mitral valve replacement about a year ago. He also has a history of lymphoma treated with radiation in the past with no further therapy. He is also treated for hypertension and elevated cholesterol. He is reported also to have a history of renal artery stenosis. In addition to the above, he has had a splenectomy and hernia repair.
ALLERGIES: He has no known drug allergies.
FAMILY HISTORY: He has no family history of intracranial aneurysms or subarachnoid hemorrhage.
PHYSICAL EXAMINATION: The patient is alert and cooperative, in no acute distress. His language is fluent. He is fully oriented. He did become tired during the interview. He was given a dose of Vicodin within the past 30 minutes, however. He has intermittent twitching of both eyes. He states he has had this for many years and related to anxiety. He states this resolves when he takes Xanax. His visual fields are full to confrontation bilaterally. His pupils are about 2 mm and equal. Extraocular movements are full. Face is symmetric. Tongue and palate are midline. Light touch sensation is symmetric and intact in the face, arms, and legs. He has symmetric 5+/5 strength throughout his extremities with no pronator drift including biceps, triceps, handgrip, hip flexion, knee flexion and extension, and plantar and dorsiflexion of the ankles. He does very well with finger tapping, finger-to-nose, and heel-to-shin testing.
DIAGNOSTIC DATA: We reviewed his CTA of the brain done yesterday. This demonstrates an ectatic cavernous right internal carotid artery. We do not believe he has an aneurysm.
IMPRESSION AND PLAN: Question of aneurysm has been raised. If present, we believe this is completely unrelated to his presentation. Of concern is his history of syncope. He cannot have an MRA to screen for vertebrobasilar insufficiency. The CTA is not a good screening test for vertebral artery origin stenosis. We would suggest at this point planning cerebral arteriography. This will probably exclude the presence of aneurysm. If he does have an aneurysm, this will allow us to assess treatment options. We will also be able to evaluate him for vertebrobasilar occlusive disease, which may be playing a role in the syncope. We discussed with him cerebral angiography, including its risks and benefits. He is inclined to proceed with this. We will plan to do so soon.
