DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Spinal epidural hematoma.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Asian male with a history of DVT and pulmonary embolus found to have lupus anticoagulant. He was subsequently placed on Coumadin quite a while back. He now has a three-day history of severe sitting low back pain with shooting bilateral lower extremity pain with cramping. The patient presented to the hospital early this morning with these symptoms. A workup for kidney stones was then performed, and once completed, his INR lab work came back and showed INR of greater than 11 at 7 a.m. this morning. MRI of the lumbar spine was then ordered and was completed by noon today. It showed evidence of a spinal epidural hematoma. We were called at approximately 3:00 this afternoon for neurosurgical evaluation and treatment. No FFP had been given, but the patient’s exam remained unchanged. Upon receiving the call, we requested 4 units of FFP be given and a STAT transfer to this hospital for neurosurgical evaluation to be performed. On arrival here, the patient is yet to receive his FFP, although was moving his extremities and had normal sensation.
PAST MEDICAL HISTORY: Significant for pulmonary embolism and DVT, lupus anticoagulant disorder, and benign prostatic hypertrophy.
PAST SURGICAL HISTORY: Significant for left knee surgery, right inguinal hernia surgery, and left jaw surgery.
ALLERGIES: None.
HOME MEDICATIONS: Coumadin 10 mg p.o. daily, Cardura, and Proscar.
SOCIAL HISTORY: The patient is married. He denies tobacco use. He drinks four beers per day.
FAMILY HISTORY: Significant for gastroesophageal reflux disease.
REVIEW OF SYSTEMS: A 14-point review of systems was discussed with the patient and is significant for as mentioned above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 86, respiratory rate 22, blood pressure 132/92, and he is on room air, 98% oxygen saturation.
GENERAL: The patient is sitting in his bed. He is unaccompanied during this evaluation. He does not appear to be in any acute distress.
HEENT: The patient’s head is normocephalic and atraumatic. The sclerae are noninjected and nonicteric. His oropharynx is clear. He has good dentition. There is no evidence of otorrhea or rhinorrhea. There is no evidence of Battle’s or raccoon sign.
NECK: The patient’s neck is supple with good range of motion. There is no Lhermitte or Spurling sign. He has no thyromegaly. No JVD. He has normal carotid pulsations.
CARDIAC: Auscultation of the patient’s heart does not reveal any evidence of murmurs, gallops, or rubs. He has normal S1 and S2 sounds.
LUNGS: Clear to auscultation bilaterally. There are no wheezes, rhonchi, or rales.
ABDOMEN: The patient’s abdomen is soft, nontender, and nondistended. There is no organomegaly.
EXTREMITIES: There is no clubbing, cyanosis, or edema. He has palpable pulses throughout.
NEUROLOGIC: The patient is awake, alert, and oriented x3. He has clear speech and normal mentation. His pupils are 4 mm and reactive to 3 mm bilaterally. Funduscopic exam reveals no evidence of papilledema. Extraocular movements are intact. Visual fields are full to confrontation. He has normal trigeminal sensation and normal facial expression. He has normal hearing to whisper. His palate is upgoing. His tongue protrudes in the midline. He has normal shoulder shrug. His strength is 5/5, normal limits, and normal tone and bulk. His sensory exam is intact to light touch and pinprick across all dermatomes in the upper and lower extremities as well as around his chest and torso. Cerebellar testing reveals no dysmetria. Cranial nerve evaluation, there is no ocular nystagmus. Reflexes are 2/2 at the biceps, triceps, 2-/2 about the patella, trace about the Achilles. There is no clonus. Toes are downgoing. Hoffmann sign is negative.
LABORATORY DATA: Reviewed outside labs performed at 5:00 this morning, reveal white count 2.3 and hematocrit of 44.6, and platelet count 248,000. Sodium 144, potassium 3.3, BUN is 11, and creatinine 0.9. His PTT is 88.6, his PT is 83.6, and his INR is 11.06.
We reviewed the patient’s MRI of the lumbar spine performed earlier today. It does show evidence of a spinal epidural hematoma with severe stenosis across multiple levels. The hematoma appears to extend from at least L1 through the sacrum and extends above this level, but could not be further evaluated due to limited imaging.
IMPRESSION AND PLAN: The patient is a (XX)-year-old male with an elevated INR with spontaneous spinal epidural hematoma with a resultant spinal stenosis. He has back pain and leg pain with a tight neurological exam, so we recommend rapid correction of his coagulopathy with FFP and vitamin K. Consult Dr. Jane Doe, his hematologist, for management of his coagulation disorder. We would recommend admission to the neurologic intensive care unit with frequent neuro checks. We would recommend surgical intervention if his exam worsens and his INR is less than 1.5. He is also to be placed on alcohol withdrawal prophylaxis protocol.
Thank you for allowing us to participate in the care of this patient.
