History
Identifying Data:
Full Name: D.D.
Address: N/A
Date of Birth: N/A
Date & Time: 8/30/2022, 10:15 am
Location: Queens Presbyterian Hospital
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: EMS
Chief Complaint: “I’m here because I thought I was having a stroke” 4 days ago.
History of Present Illness:
79 year old male with PMH of HTN, HLD, CKD, DM, A-fib, & chronic pancreatitis. Also has h/o multiple ED visits within the past 2 months for recurrent GI bleed. Pt presented to the ED 4 days ago for possible stroke. Pt notes he was being changed when he started to notice slurred speech, facial drooping, & left upper extremity weakness, with symptoms beginning in that order. I should have asked how long the symptoms lasted for. At which point, he was immediately brought into the ED for stroke work up. Today patient notes he has been able to take a few steps and initial symptoms have resolved. Pt is currently on multiple medications but noted that he was ordered to stop Eliquis at some point within the last 2 months that may have prompted stroke, but he has now resumed the medication. I should have asked why he was told to stop medication and for how long he was off it.
Past Medical History:
Hypertension x 13 years, on Metoprolol 200mg PO once daily, Losartan 50mg once daily
Hyperlipidemia x15 years, on lovastatin once daily
Chronic Kidney Disease x 10, on furosemide 40 mg twice a day
DM x 10, on metformin 300 mg once daily, Januvia 100mg once daily
A-fib x 10, on Eliquis 5 mg twice a day
Chronic Pancreatitis x 10, on pancrelipase 24,000 units once a day
Glaucoma x 5 years, on Latanoprost 5% 1 drop at bedtime
Childhood Illnesses- chicken pox, measles, pneumonia 2x. Doesn’t remember what years.
Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent Jan.2022)
Screening test and results – Screening colonoscopy 2022, GI bleed.
Past Surgical History:
Denies past surgeries.
Blood transfusion 5x between July 10-30 of 2022.
Medications:
Metoprolol 200mg PO once daily
Losartan 50mg once daily
Lovastatin once daily
Metformin 300 mg once daily
Januvia 100mg once daily
Eliquis 5 mg twice a day
Pancrelipase 24,000 units once a day
Latanoprost 5% 1 drop at bedtime
Clotrimazole 1% twice a day
Fluticasone 50 mcg once daily each nostril
Ketoconazole 2% once daily
Selenium Sulfide 2.5% once daily
Denies use of herbal supplements.
Allergies:
NKDA
Family History:
Mother – Deceased at 84 years old, breast cancer
Dad – Deceased at 72, MI
Did not ask about children.
Maternal/paternal grandparents – Deceased at unknown age & unknown reasons
Family history of cancer, diabetes and myocardial infarctions.
Social History:
Mr. DD is married, retired and lives in nursing home.
Habits – Denies current tobacco use. Quite smoking in 1980s. No history of illicit substances. He drinks alcohol 2-3 x day for several days a week. Denies drinking caffeine.
Travel – No recent travel.
Diet – He states he has a well-balanced diet.
Exercise – Denies exercising.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – Pt is heterosexual. He has not been sexually active for 10 years.
Denies history of sexually transmitted diseases.
Review of Systems:
General – Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies, headache, vertigo or head trauma.
Eyes – Denies lacrimation, pruritus, visual disturbances or photophobia. Does not wear glasses. Does not recall what visual acuity or pressure is. Last eye exam 2022.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction or epistaxis.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam 2022.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Has a history of hypertension x 13 yrs. Admits to having irregular heart beat due to A-fib. Denies chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation. Admits to being treated for rectal bleeding and blood in stool. Colonoscopy July 2022.
Genitourinary system – Denies nocturia, dysuria, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – N/A
Musculoskeletal system – Denies muscle/joint pain. Denies deformity or swelling, redness or arthritis.
Nervous –Denies seizures, headache, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Blood transfusion 5x July 2022.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General: Male appears clean & well groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. No signs of acute distress, appears as stated age.
Vital Signs: BP: (R) Seated 123/79 P: 96 beats/min, regular
(L) Seated 125/80
R: 17 breaths/min, unlabored O2 Sat: 98% Room Air
T: 36.7 degrees C (oral)
Height: 72 inches Weight: 180 lbs BMI: 24.4
Head, Skin, & Nails
Hair: Average quantity and distribution. White color. Straight texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout
Eye Exam
Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink.
Visual acuity uncorrected – 20/50 OS, 20/50 OD, 20/50 OU (pt couldn’t move to do this part)
Visual fields full OU. PERRLA , EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Ear Exam
Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external
Auditory canals AU. TM’s pearly white/intact with light reflex in good position AU. Auditory acuity intact to whispered
Voice AU. Weber midlines/Rinne reveals AC>BC AU.
Nose & Sinuses Exam
Nose – Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink
& well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without
lesions / deformities / injection / perforation. No foreign bodies. (couldn’t move patient to do this to get a good view)
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth & Pharynx
Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to
Palpation; continuity intact.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate (give grade of tonsils). Uvula pink, no edema, lesions
Neck Exam
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted. (Couldn’t move patient to go around behind him)
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.
Lungs –Clear to percussion & auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: JVP is 2.5cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in midclavicular line.Carotid pulses are 2+ bilaterally without bruits. Irregular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebounding noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Pelvic Exam:
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.
Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.
Assessment: Patient suffered from a stroke most likely due to discontinuation of Eliquis which could have been causing recurrent GI bleeds.
Plan: Continue current medical management. Follow-up with cardiologist to re-evaluate use of Eliquis for A-fib & management to prevent possible future strokes.
DDx:
- Stroke
(I know we are supposed to list 5 DDx, however, my patient was already diagnosed and currently being treated and observed).
