DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: To provide a neurobehavioral status examination of the patient secondary to hypoxia versus anoxia.
PRESENTING DIAGNOSIS: Anoxia versus hypoxic encephalopathy.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old Hispanic gentleman, right-handed, who was healthy otherwise until MM/DD/YYYY, when he was driving to work and suddenly lost consciousness over a period of seconds. The patient was witnessed to have cardiopulmonary arrest by his wife who initiated CPR efforts. Paramedics were summoned and within 3 minutes arrived on the scene and found him in ventricular fibrillation requiring cardioversion x3. The patient was then stabilized and transported emergently to the hospital where code efforts continued and difficult intubation was performed.
Urgent heart catheterization was negative for blockage; however, the patient did not initially respond neurologically. An electroencephalogram was provided, which indicated diffuse slowing. Head CT with contrast was negative for intracranial bleeding. The patient was seen in consultation with Neurology. The patient was eventually deemed stable to place on the neurology step-down unit, and this is where the consultation was initiated. The patient has been showing steady recovery and improvement.
In talking with the patient’s wife, she indicated that there was approximately 3-1/2 minute delay from the time of the collapse to the time of the paramedics arriving.
RADIOLOGY STUDIES: FLAIR and T2-weighted images indicated subtle hyperintensity involving the basal ganglia bilaterally, especially within the head of the caudate nuclei and lentiform nuclei. The appearance was most likely related to hypoxic injury. Ventricular size was within normal limits. There was no extra-axial collection or intracranial mass effect. Extensive paranasal sinus inflammatory disease was identified. A followup CT scan revealed no intracranial change from the prior examination, which was performed on MM/DD/YYYY and MM/DD/YYYY. The EEG on MM/DD/YYYY revealed abnormal awake and sleep EEG due to the presence of generalized swelling suggestive of encephalopathy.
PAST MEDICAL HISTORY: As noted above.
ALLERGIES: None noted.
MEDICATIONS: Enalapril, metoprolol, Keppra, Norvasc, Pacerone, guaifenesin, nystatin, antibiotics, Prevacid daily, Cipro, and Lovenox.
FAMILY MEDICAL HISTORY: Significant for sudden death of his mother secondary to brain hemorrhage. The patient also had hernia repair x2. According to the patient’s wife, he also had exposure to high voltage wire 30 years ago. Reportedly, the patient went back to work relatively soon after the shock injury. There apparently were no subsequent effects.
PAST PSYCHIATRIC HISTORY: Unremarkable.
SOCIAL HISTORY: The patient is married.
SUBSTANCE HISTORY: Noncontributory.
EXAMINATION RESULTS: Of note, the date of initial consultation, the patient had returned from PEG tube placement and so was still recovering from the residual effects of anesthesia. Therefore, the examination was carried over to a second day to be able to reduce the impact of those effects on his current performance.
The patient was fully alert and oriented to himself, the current situation of being in the hospital. The patient was pledging cooperativeness with the patient’s family.
With regard to his current cognitive function, the patient was demonstrating impairment. Reductions in attention and processing were noted. They were improved significantly from prior reports. Overall, executive functions, although are improving, still remain with residual impairment. At times, the patient could be somewhat impulsive and sometimes cannot self-correct behavior. No portion of this is also attributed to the changes in behavior secondary to his physical level of function. Memory has not been fully evaluated at this time though family report indicates increasing memory functions. Remote memory appears to be improving substantially. Thought process and thought content appear to be mood congruent at this time.
With regard to behavioral activity and agitation, at the time of evaluation, the patient was doing well. The patient had had prior days of agitation and irritability requiring medications as well as safety mechanisms and sitters. Again, the patient was slightly more sedated than typical secondary to coming back from the procedure. The patient is still having difficulties with thought process going from sleep to wake that will be described below. Overall, the patient is a safety risk and a fall risk secondary to current level of physical function as well as cognitive impairment.
With regard to physical function, there was no sensory impairment noted. Motor functions reveal ataxic movement of the upper and lower extremities with impairment within the hands and forearms greater than other areas of function. The patient has balance difficulties and coordination difficulties. Overall processing and motor function are also reduced.
With regard to affect and mood, the patient’s affective expressions were appropriate generally. At times, the patient was not demonstrating any overt signs of anxiety, depression, worries, and concerns. However, insight and awareness are also continuing to improve and maybe limiting his overall affect and mood expressions. This will need to be further evaluated.
With regard to vegetative features, the greatest difficulty at this time seems to be managing and regulating sleep. The patient normally has 6 to 8 hours of sleep per night. At this time, the sleep has been somewhat intermittent, and at times, at night, he has been trying to get up or has greater confusion. Family members have also been staying to assist in his efforts and currently has a sitter in place.
With regard to appetite, this cannot be fully evaluated at this time secondary to the patient just having PEG tube placement. Energy level is reduced. Fatigue is noted. The patient does nap during the day.
IMPRESSION: At this time, neuropsychological impressions are consistent with cognitive disorder, not otherwise specified, secondary to hypoxic encephalopathy. The patient is demonstrating recovery based on chart review and based on current presentation and findings. The patient is a substantial safety risk secondary to motor impairment as well as to cognitive limitations. The patient is expected to continue to improve.
Axis I: Cognitive disorder, not otherwise specified.
Axis II: Deferred.
Axis III: See history above, including hypoxic encephalopathy.
Axis IV: Current psychosocial stressors include current disability and family stress secondary to current medical issues.
Axis V: Current Global Assessment of Functioning equals approximately 45-50. Past year Global Assessment of Functioning equals 90 or better.
ASSESSMENT, PLAN, AND RECOMMENDATIONS: Continued treatment at inpatient rehabilitation will be indicated. The patient is already beginning to demonstrate significant improvement in functions but does require continued support and structure within an inpatient environment and also continues to require overall medical supervision as well as behavioral and cognitive supervision.
Physically, the patient is also demonstrating significant impairment with the ability to transfer, ambulate, and self-care tasks that would require inpatient continued rehabilitation efforts. Other recommendations will include discussion during the behavioral rounds to make sure he is meeting his discharge goals. Also working with the patient with regard to cognitive improvement as well as behavioral improvement. We already discussed the case with Dr. Jane Doe of psychiatry for overall behavioral management.
Continued use of the sitters would be indicated, and we will be training them with a behavioral observation scale that will be required to be completed at night so that we can get a better handle on when he is awakening, which may help us to understand his current medication regimen and its effects. We have already begun working with the patient’s family with regard to education and support. The patient would benefit from a full neuropsychological evaluation at the time of his hospital discharge or just prior to then make recommendations for outpatient followup. The current evaluation results appear to be valid. Any additional information not available at the time of the assessment will be considered later.