For my LTC rotation, I had the opportunity of presenting my patient cases to Professor Davidson. Out of the 2 cases I presented, I found the case of the man with left sided weakness, dysarthria and impaired gait the most interesting. He was a 77 y/o male with T2DM (on insulin and metformin with A1c of 10.5 2/2023), h/o stage 1B (T2aN0M0) sarcomatoid carcinoma of lung s/p bilobectomy (2012), prostate cancer with mets to ribs on ADT+abiraterone+prednisone since 2018, COPD 2/2 tobacco use, HTN, treated HCV, chronic PE (on Eliquis), and MDR TB treated in 1994 presenting from Manhattan VA s/p acute medical management of hyperglycemia for short term rehab s/p right pontine stroke with residual left sided weakness, dysarthria, and imparied gait since evening of 6/28. Per discharge summary (7/6/23), acute medical workup significant for uncontrolled T2DM. Pt reports left sided weakness and residual “heaviness” of left leg. He also states that intially he was having slurred speech and immobility but symptoms have since then resolved. He notes speech is intermittently slurred. Said he continues to feel a little bit “wobbly” when he walks. Denies headache, dizziness, numbness, changes in vision, chest pain, SOB, N/V/D, abdominal pain, fever or chills.

On exam, the patient had deviation of the tongue to the right, finger to nose was asymmetric and his gait was slow and unsteady but he ambulated without assistance.

For labs, the most recent fingerstick glucose was 194. 

Based on the physical exam findings and history, it was determined that the residents prognosis was fair and that he would benefit from PT/OT with the goal of improving his functional status back to baseline. 

After receiving feedback from my site evaluator, it was discussed that I should begin with the status of the patient before the new episode and then the new episode itself. However, I was still able to appropriate capture and state the course of events leading up to the patient’s admission the St. Albans. Another thing the professor told me to include was whether or not the patient had received their shingles or pneumococcal vaccines. Last, but not least, I was told to include an assessment for everything single problem from my problem list.