REASON FOR CONSULTATION: Syncope.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who was in his usual state of health up until yesterday when he was on a roof, coming down the ladder, and he suddenly had an episode where he fell approximately 7 feet and sustained a right clavicular fracture. The patient states he felt as if he was going to pass out. He states that he awoke, he was not confused, he did not bite his tongue, he did not lose urine. He states similarly that he had a similar episode a few weeks ago. At that time, he was not on a roof however. He states that these events are precipitated with chest-like pain and then he loses consciousness. He thinks he may have had one when he was riding his motorcycle back in June or July of last year but he is not sure.
REVIEW OF SYSTEMS: He denies fever or chills. Head, ears, eyes, nose, and throat: No complaints. Pulmonary: No shortness of breath or cough. Cardiac: He did admit to having chest pain yesterday. Neurologic: He denies any seizure-like activity. Denies cranial nerve deficits. Denies weakness in his arms or legs or gait abnormalities.
PAST MEDICAL HISTORY: Significant for 2 myocardial infarctions in the past at a young age, in his 30s. No other medical history.
SOCIAL HISTORY: He only drinks socially. No tobacco or drugs.
FAMILY HISTORY: Strong cardiac history in the young. Both parents died of a heart attack and he had 2 close family members on his mother’s side that died in their 30s of cardiac disease.
ALLERGIES: NONE.
MEDICINES: He is on full-dose aspirin as well as on Lopressor.
PHYSICAL EXAMINATION:
GENERAL: A (XX)-year-old gentleman lying in bed in no acute distress.
VITAL SIGNS: Stable. His blood pressure is 102/74, pulse 92, temperature 96.2, and respiratory rate 20.
HEENT: Head is atraumatic and normocephalic. Ears unremarkable. Eyes: Pupils reactive to light. Nose and throat are unremarkable.
NECK: Supple. No bruit.
HEART: Regular. S1, S2. No murmurs.
LUNGS: Clear.
ABDOMEN: Soft, nontender, nondistended.
MUSCULOSKELETAL: He has positive clavicular pain to palpation.
NEUROLOGIC: The patient is awake, alert, and oriented to person, place, and time. His speech, language, repetition all intact. Cranial nerves: His pupils equally round, reactive to light and accommodation. Extraocular muscles are intact. No nystagmus. Visual fields are normal. No facial asymmetry. Tongue is midline. Motor: He has normal bulk and tone throughout without any signs of weakness except around the right shoulder area. He cannot give full resistance because of the pain of the fracture in his clavicle. Lower extremity is 5/5. No leg lag. DTRs 1+, symmetrical. Toes: He withdraws bilaterally. Finger-nose-finger is intact. Gait is deferred until complete cardiac evaluation.
IMPRESSION: A (XX)-year-old man with a questionable syncope. Syncopal episode versus questionable seizure. History of cardiac disease. Questionable syncope secondary to cardiac event.
PLAN: Check routine EEG from a neuro standpoint. He will have a complete cardiac evaluation. He will be followed by Orthopedics for his right clavicular fracture with pain management. Also, the patient will remain on full-dose aspirin at this point in time unless deemed necessary to be changed by Cardiology. He will have a 2D echo. Possibly a stress test as per cardiology’s recommendation. Continue observing him neurologically per protocol as well as for possible seizure precautions. Depending on the outcome of the EEG and other studies the patient will have, we will make further recommendations at that point in time.
