DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Consultation requested for headache. CHIEF COMPLAINT: The patient is a (XX)-year-old right-handed female complaining of headache. HISTORY OF PRESENT ILLNESS: The patient notes that she has had migraine headaches since she was (XX) years old. Her migraines tend to have consistent features; in addition, sometimes have variable symptoms. For example, the patient notes that when she was a teenager and early on her migraine history, she would have left facial droop and paresthesias of the left upper extremity prior to her headaches. More recently, the pattern has changed, to be described further on below. The patient notes that her usual migraine frequency is once or twice a month, for the most part, along with her menses, although they can occur independent of her menses less often. That has been her pattern for the past 1-1/2 years, but prior to that, she was only having one or two migraines per year. In November, her gynecologist began to try hormonal manipulation to see if the migraines could be better controlled. The patient started by using a NuvaRing and if anything this seemed to increase the frequency of her migraines, as she has had a migraine headache on the average of once a week since this was instituted. The patient had another migraine on Monday and called her gynecologist and decided to go off the NuvaRing at that time. Instead, the gynecologist started Camila 0.35 mg daily, which she took for three days prior to admission. She notes that her menses had been very irregular and in fact that she has been having some amount of vaginal bleeding for the past 1-1/2 months as well. She is uncertain as to whether the additional hormones she has gotten has changed that pattern. Typically, the patient does not take any treatment for her migraine; although, she has found that sleep will take away the major portion of the pain, and that is how she has been treating these. She tries Tylenol Extra Strength, but it does not give relief. Her migraine typically begins with visual disturbances. She will either have scotomata in her peripheral visual fields or scintillating scotomata in the same regions. Yesterday at 10 o'clock, she had the sudden onset of scotomata, which lasted for 15 minutes and then these became scintillating for another 15 minutes. Next, the patient developed her typical weakness of the left upper extremity, which has been an associated feature with her migraines for many years now. This is more of a heaviness without true weakness. Almost simultaneously, she developed paresthesias of her right upper extremity, which is a symptom that she has never had. These symptoms lasted for 15 to 20 minutes. In addition, the patient had some amount of slurred speech during these events. Subsequently, the patient developed atypical headache, which usually involves the right cranium much more so than left. This is usually behind the eye on the right and, yesterday, also involved the vertex and then spread in atypical fashion to right capital occipital artery regions. The quality of the headache is that of a throbbing and pulsating sensation. There is anorexia and nausea associated with it, with occasional vomiting. The headache typically worsens with coughing, sneezing, straining for a bowel movement, or otherwise engaging in Valsalva maneuver. The patient denies focal weakness of a significant nature, other numbness, tingling, or dysesthetic sensations of the face or lower extremities. No other visual complaints. The patient has chronic tinnitus in the left ear. She complains of an orthostatic sense of lightheadedness and presyncopal sensations without vertigo, which occurs when arising rapidly from the supine or seated position. The symptoms are not precipitated by rapid movements of the head upon neck or by bending over. Sometimes she feels these symptoms even when she is just sitting and doing nothing. No other bulbar symptoms. No history of recent or remote head, neck or low back trauma, with or without loss of consciousness. Denies previous CNS infections. No bowel, bladder or sexual dysfunction. PAST MEDICAL HISTORY: Known mitral valve prolapse. The patient denies diabetes, hypertension, myocardial infarction, cardiac arrhythmia, anginal pectoris, current chest pain or pressure, kidney or liver disease, previous stroke, epilepsy or other neurologic or psychiatric illness. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She denies abuse of tobacco, alcohol, prescription drugs or illicit substances. ALLERGIES: No known food, drug or contrast material allergies. MEDICATIONS: See HPI. Vicodin as necessary for lingering headache pain. REVIEW OF SYSTEMS: Please see the HPI for neurologic and other pertinent review of systems, otherwise the following systems are noncontributory including constitutional, eyes, ears, nose, and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin and/or breast, endocrine, hematologic/lymph, allergic/immunologic and psychiatric. PHYSICAL EXAMINATION: LABORATORY STUDIES: On admission, CBC is normal. Electrolytes are normal other than CO2 of 22. Normal SMAC and magnesium. DIAGNOSTIC STUDIES: CT scan of the brain without contrast infusion is normal. Results of the MRI of the brain and MR angiogram are pending. IMPRESSION: It appears that the patient suffers from migraine headaches with aura and other variable complicated symptomatology, which in the past has been primarily catamenial in its nature. However, more recently, the patient has had an increase in the frequency of her migraines, possibly related to trials of estrogen and progesterone that have been initiated by her gynecologist versus the possibility that she is entering into hormonal fluctuations related to menopause as an alternative explanation. RECOMMENDATIONS: The patient has recently decided to discontinue her hormone replacement therapies and I agree with this approach. With some time, it might be possible to see as to whether the migraines were increasing in frequency as a result of these treatments, or whether they will continue to be this frequent, in which case it may be related to the earliest phases of menopause. I agree with the current narcotic analgesic treatment that the patient is receiving for her lingering migraine headaches. The results of the MRI scanning of the brain, as well as MR angiography are currently pending. As an outpatient, the patient should be on a migraine prophylaxis with either beta blockers, tricyclic antidepressant medications or anticonvulsants like Depakote. These would be treatments that would be best applied on an outpatient basis. The patient is asked when she leaves the hospital to begin taking an Ecotrin tablet 325 daily with her breakfast. At times, even the simple use of the daily aspirin therapy will provide adequate prophylaxis against migraine headaches. For symptomatic relief, she is asked to take Excedrin Extra Strength and she will take 2 tablets every 3 to 4 hours for her more severe migraines. If that should fail and the migraine continues to progress, then as an outpatient, the patient should resume the use of Midrin, which she has used successfully in the past, taking 1 or 2 capsules of the brand medication (as the generic clearly does not work as well) - up to a maximum of 6 in any one day. Her use of sleep as rescue therapy is also entirely appropriate if nothing else works. The patient agrees to follow up with me in the office after discharge. --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- |