Thank you. When requesting this information, is there a standard form for dictating these types of EEG procedures? The EEG was being performed for seizure evaluation. See consult below.
REASON FOR CONSULTATION: Altered mental status.
HISTORY OF PRESENT ILLNESS: This is a 63-year-old right-handed gentleman
with a past medical history of hypertension, smoking, or alcohol or
recreational substance abuse who was admitted for altered mental status.
The patient was not able to provide a history. The following information
is based on interview with his wife who has been married with him for more
than 20 years of time.
The wife relates that the patient had not been doing well mentally for
about one week of time, which is similar to periodic medical problems he
has had, but the difference of this one is longer and he has not show
signs of recovery
The wife relates that has ahs ahd similar medical problems periodically over
the last 20 years' time or since the early 1990s. Each time when he has
problem, he becomes confused and sometimes even not able to remember or
recognize family members. He also has unsteady gait and he falls. He
complains of pain all over, but in about one- week time, the patient
usually recover back to his baseline. This happens once in every six months
of time. The patient has been seen by University and
Clinic. His family doctor is Dr. B and his neurologist is Dr. L. The
patient has had numerous MRI scans to the brain and he also has had MRI to the
neck, back, and almost every part of his body. He also had numerous EEGs
according to his wife, but problem has been found. As a result, no specific
treatment has been given.
In 1996, the patient had a fall, but which was not witnessed. Wife found
him on the ground nonresponsive. The patient was admitted to the hospital
where he stayed for two months of time and also had a surgery. The
patient was nonresponsive and he did not improve mentally until four or
five days after he was admitted to the hospital.
The patient has a long history of heavy smoking. He also drinks alcohol
excessively and abused illicit drugs. However, he always hides his
substance abuse problem away from his wife. As a result, she does not
know the details. Wife suspects that the problem is still ongoing.
In the intervals of his periodic altered mental status, the patient is able to
walk, but his walk and gait is not normal; however, the wife has problem to
specify it. Typically, the patient is oriented to place and person, and he
knows the time. He does not have headache. No bowel or bladder control
problem, but he does have constipation. He was hard of hearing, but no vision
problem; however, he needs eye glasses. He has no symptoms of seizure
disorder or strokes. According to the wife and parents, there is no focal
weakness she can tell. The patient had pain all over the neck and back. He
has had an MRI to the lumbar and the cervical region and the etiology still
remained unknown. Recently, there are no obvious chills, fever, or heat or
cold intolerance. No weight changes the wife can tell.
PAST MEDICAL/SURGICAL HISTORY: Hypertension, dyslipidemia, chronic pain
in the back, neck, and joints, head injury, status post surgical
treatment, prostate cancer, status post surgical management, and knee
MEDICATIONS: Zocor, folic acid, risperidone, multivitamin with mineral
supplementation, vitamin B1 supplementation, aspirin, and docusate.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. He has chronic heavy tobacco
smoking and heavy alcohol abuse and illicit drug abuse.
FAMILY HISTORY: Cancer. Mother also had Alzheimer dementia. No seizure
disorder according to the wife.
REVIEW OF SYSTEMS: Also as described. The other systems are unremarkable
or not reliably obtainable.
PHYSICAL EXAMINATION: GENERAL: The patient looks well nourished and well
developed and looks slightly pale in the face, but in no acute distress.
VITAL SIGNS: Blood pressure is 128/76,
respirations are 16, and pulse rate is 110. HEENT: Normocephalic. His
mucus looks dry. NECK: Supple. No carotid bruits. LUNGS: Clear to
auscultation. HEART: Regular rate. S1 and S2. ABDOMEN: Soft and
nontender with no bowel sounds. NEUROLOGIC: The patient's eyes are
closed. He is easily arousable. He smiled to me and also raised his
right hand to me. He speaks with slurred speech. He only followed some
of my verbal commands, but apparently he does not have aphasia, but his
speech is slurry and which is also evident before he came to the hospital
according to his wife. Cranial nerves II through XII showed equal, round,
and reactive pupils. He can move his eyes spontaneously, but he does not
follow. There looks some limitation on his eye movements to all the
direction. I do not see nystagmus spontaneously or evoked or both. No
obvious facial weakness. He looks to have normal sense to noxious stimuli
to both sides of his face. Tongue and palate in the midline. The rest of
his cranial nerve examination is not reliably obtainable. Motor
examination, no bulk tone. No tremor. No other abnormal spontaneous
movement. He moves all the limbs and the muscle strength is no less than
3/5 in the arms and 2-3/5 in the legs. Reflexes are symmetric without
pathological reflexes. Sensory examination, it looks like he has no
problem to perceive noxious stimuli to all the limbs. The finger-to-nose
test is not able to obtain properly. Gait test is deferred because of the
patient's current situation.
DIAGNOSTIC/LABORATORY DATA: CT brain study showed no acute abnormalities.
Chest x-ray showed no evidence of cardiopulmonary process. White count
was 14.5, platelets were 282,000, hemoglobin was 16.8, and MCV was 98. PT
was 12.3, INR was 1.138, and PTT was 27. Sodium was 146, potassium was
4.1, chloride was 109, bicarbonate was 30.6, BUN was 26, creatinine was
1.21, glucose was 145, calcium was 10.1, and magnesium was
2.2. Total bilirubin was 1.4, AST was 53, ALT 48, and alkaline
phosphatase was 88. Troponin was normal. Total protein was 8.3 and
albumin was 3.9. Urine drug screen was negative. Urinalysis was negative
ASSESSMENT AND RECOMMENDATIONS: It is not clear what is going on with the
patient. I do not think the history is to the detail because the wife
has claimed that she does not know what has happened to him in detail and he
always hid his alcohol and drug problem. This problem has been going on for
20 years according to the wife. The differential diagnoses should include at
least: Wernicke encephalopathy due to his alcohol problem, encephalopathy due
to metabolic or toxic issues, possible seizure disorder, or possibly stroke as
well; however, it is not typical for any of them. The patient also looks
dehydrated to me and I started him with IVS and banana bag. I will keep
monitoring and I will consider MRI brain scan.
Thank you very much for giving me the opportunity to take care of this
pleasant gentleman. I will follow up the patient with you.