Neurosurgical Consultation Note

Neurosurgical Consultation Note Referral Source and Indication: Referred by Dr. Sarah Chen, General Practitioner, due to persistent, worsening headaches and new-onset focal neurological deficits, specifically left-sided weakness, raising suspicion for an intracranial lesion. History of Present Illness: Patient is a 58-year-old male presenting with a 3-month history of progressive headache, primarily frontal and temporal, described as dull and throbbing. Initially intermittent, headaches have become daily and are no longer relieved by over-the-counter analgesics. Over the past 2 weeks, he has developed noticeable left-sided arm and leg weakness, leading to occasional falls. He reports mild speech difficulty (word-finding) but denies any visual changes, seizures, numbness, or bowel/bladder dysfunction. No altered consciousness reported. Past Medical and Neurosurgical History: * Hypertension, well-controlled with Ramipril. * Hyperlipidaemia, managed with Atorvastatin. * No previous neurological procedures or diagnoses. * Family history significant for paternal stroke at age 70. Medication and Allergy History: * Ramipril 5mg daily * Atorvastatin 20mg daily * Paracetamol PRN * Allergies: Penicillin (rash) Neurological Examination: * Level of consciousness: Alert and oriented x 3. GCS 15. * Cranial Nerves: Pupils equal, round, and reactive to light (PERRLA). Extraocular movements intact. Mild left facial droop. Gag reflex present. Visual fields full to confrontation. * Motor strength: * Right upper extremity: 5/5 * Left upper extremity: 3/5 (deltoid, biceps, triceps) * Right lower extremity: 5/5 * Left lower extremity: 4/5 (hip flexors, knee extensors) * Sensation: Intact to light touch, pinprick, and proprioception bilaterally. * Reflexes: Deep tendon reflexes 2+ bilaterally and symmetrical, except for left upper extremity which was 1+. Plantar responses flexor bilaterally. * Coordination: Dysmetria on finger-to-nose and heel-to-shin on the left. * Gait: Ataxic with a tendency to veer to the left. Requires steadying. * Signs of raised intracranial pressure: No papilledema noted on fundoscopy. No Cushing's triad. Imaging and Diagnostic Studies: * MRI Brain (dated 25 October 2024): Revealed a 4x3x3.5 cm heterogeneously enhancing lesion in the right frontal lobe with significant surrounding vasogenic oedema causing mass effect on the right lateral ventricle and a 5mm leftward midline shift. * CT Head (dated 20 October 2024): Showed a large right frontal lobe mass with surrounding oedema. Diagnosis or Impression: Right frontal lobe mass, highly suspicious for glioblastoma multiforme (GBM) given rapid progression of symptoms, size, and oedema on imaging. Differential diagnosis includes metastatic lesion or high-grade astrocytoma. Management Plan: 1. Neurosurgical referral for urgent craniotomy and biopsy/resection of the right frontal lobe mass. 2. Pre-operative workup: full blood count, electrolytes, coagulation profile, chest X-ray, and ECG. 3. Commence Dexamethasone 8mg BID to reduce cerebral oedema. 4. Oncology consultation for post-operative management planning, including radiotherapy and chemotherapy. 5. Physiotherapy and Occupational Therapy assessment post-operatively for rehabilitation. 6. Follow-up appointment to be scheduled post-discharge to discuss pathology results and further management.