History
Identifying Data:
Full Name: M.W
Address: N/A
Date of Birth: N/A
Date & Time: 03/30/2023, 1:00pm
Location: NYPQ
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “I was feeling very dizzy and couldn’t walk” x 1 day.
80 y/o female, right hand dominant, former smoker with 15 pack-year history, with PMHx of stroke 8 years ago with right mild hemiparesis, COPD, HTN, HLD, hypothyroidism, A-fib on Eliquis, Lung CA s/p mediastinal lymph node dissection and left side upper lobe resection in 2021, s/p recent admission for mechanical fall with facial injury (3/18/23), brought in by EMS presents for feelings of constant dizziness x 1 day that progressively got worse throughout the day. Pt reports that she woke up and started to feel dizzy around 11:30am at which point she checked her BP which she reports as 140/100. Pt was concerned with BP and constant dizziness and contacted her PMD who recommended taking a second dose of diltiazem 120mg PO. After taking a second dose, pt’s dizziness worsened at which point she called EMS. Pt notes that EMS had to break down her door since dizziness was so severe that it rendered pt unable to walk. Today patient still endorses feeling dizzy. Pt also admits she had a recent fall 1 week ago but did not stop her Eliquis at that time. Denies any weakness, slurred speech, visual disturbances, headaches, loss of hearing, ringing of the ears, leg pain, numbness, recent travel, long car rides, or facial droop.
Initial DDx:
dizziness secondary to overdose of blood pressure medication
BPPV
Embolic Stroke
Ischemic stroke
Past Medical History:
COPD
HTN
HLD
CVA
Paroxysmal A-fib
Lung cancer
Osteoporosis
arthritis
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent 2022)
Screening test and results – Colonoscopy (01/23/23) – negative; Upper GI endoscopy (01/23/23) – negative
Past Surgical History:
Mediastinal lymph node dissection and left side upper lobe resection (2021)
Denies any blood transfusions.
Medications:
Albuterol HFA 108 mcg/act aerosol solution inhaler, 2 puffs every 6 hours
Ellipta 62.5-25 mcg/act aerosol powder breath activated, 1 puff by mouth daily
Apixaban 5mg tablet, 1 tablet by mouth 2 times daily
Atorvastatin 40mg tablet, 1 tablet by mouth daily
Diltiazem 120mg capsule ER 24 hour, 1 capsule by mouth daily
Enalapril 10mg tablet, 1 tablet by mouth daily
Fluticasone-umeclidin-viliant 100-62.5 mcg/act aerosol powder breath activated, 1 puff daily
Levothyroxine 75mcg tablet, 1 tablet by mouth daily
Denies use of herbal supplements.
Allergies:
NKDA
Family History:
Mother – deceased at unknown age
Dad – MI, deceased at unknown age
Maternal/paternal grandparents – Deceased at unknown age
Denies family h/o diabetes and cancer.
Social History:
Miss MW is widowed and lives alone.
Habits – Admits to being former smoker and quit ~30 ago. Smoking included cigarettes. Has never used smokeless tobacco. No history of alcohol abuse, denies history of illicit substances. Denies drinking coffee.
Travel – No recent travel.
Diet – She states she has a well-balanced diet.
Exercise – Denies exercise.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – Pt is heterosexual.
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 – Admits to dizziness and head trauma that occurred 1 week ago. Denies headache.
Eyes – Denies lacrimation, pruritus, visual disturbances. Does not wear glasses. Does not recall when her last eye exam was or what his visual acuity or pressure is.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, epistaxis, or nasal polyps.
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. Does not recall when last dental exam was.
Pulmonary system – Denies dyspnea on exertion and cough. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Admits to having 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.
Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – Pt is post-menopausal.
Musculoskeletal system – Admits to muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
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. Denies blood transfusion.
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: Female appears clean & casually-groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. Does not appear to be in acute distress. Pt appears as stated age.
Vital Signs: BP: (R) Seated 139/57 P: 64 beats/min, regular
(L) Seated 140/61
R: 17 breaths/min, unlabored O2 Sat: 95% on room air
T: 36.4 degrees C (oral)
Height: 62 inches Weight: 243 lbs BMI: 44.4
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 – 20/40 OS, 20/40 OD, 20/40 OU. 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/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne 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.
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. 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.
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 – No wheezing, stridor or rhonchi. 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, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge.
Pelvic Exam:
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous, 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. 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.
Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.
Reflexes:
| Biceps | Triceps | Brachioradialis | Patellar | Ankle/Achilles | Babinski | |
| Right | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
| Left | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.
Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /
ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
NIHSS: NIH Stroke Scale
Level of Consciousness: Alert, keenly responsive
LOC Questions: Answers both questions correctly
LOC Commands: Performs both tasks correctly
Best Gaze: Normal
Visual: No visual loss
Facial Palsy: Normal symmetrical movements
Motor Arm, Left: No drift
Motor Arm, Right: No drift
Motor Leg, Left: No drift
Motor Leg, Right: No drift
Limb Ataxia: Absent
Sensory: Normal, no sensory loss
Best Language: No aphasia
Dysarthria: Normal
Extinction and Inattention: No abnormality
Total NIHSS: 0
GCS: Glasgow Coma Scale
Eye Opening: Spontaneous
Best Verbal Response: Oriented
Best Motor Response: Obeys commands
Glasgow Coma Scale Score: 15
Dysphagia Screen:
Modified Rankin (Modified Rankin Interval: Pre-stroke): Modified Rankin Score: 3
Modified Rankin Score: Moderate disability. Requires some help, but able to walk unassisted.
Labs:
NA 134*
K 4.4
CL 97*
CO2 23
BUN 14.0
CREATININE 0.89
GLU 95
CA 9.9
ANOINGAP 14
WBC 6.72
HGB 10.5*
CRIT 34.2*
PLT 376
NEUTP 68.8
LYMPHP 19.50
MONOP 7.4
EOSP 2.80
TP 8.1
ALB 4.6
GLOB 3.5
TBILI 0.5
DBILI 0.1
IBILI 0.4
SGOT 23
SGPT 25
ALK 168*
PT 13.3*
INR 1.14*
APTT 29.6
TSH 1.36
CHOL 221
HDL 21
TRIG 176.0
Imaging:
CT Head w/o IV Contrast (3/30/23):
No intra or extra axial fluid collections are visualized. No mass effect or midline shift is seen.
The ventricles and sulci are prominent, age appropriate and stable.
There are periventricular and subcortical hypodensities likely related to chronic microvascular ischemic changes. There is no acute intracranial hemorrhage.The osseous structures and paranasal sinuses are unremarkable.
CTA Head & Neck: CTA head and neck showed no high-grade stenosis or occlusion
EKG: sinus bradycardia at 58 bmp, no ischemic changes
Differential Diagnosis After:
BPPV
Dizziness secondary to overdose of blood pressure medication
Embolic stroke
Assessment: 80 year old woman with right hand dominant with HTN, Hyperlipidemia, PAF on Eliquis, Stroke 8 years ago with mild right hemiparesis, COPD, Lung CA s/p mediastinal lymph node dissection and left side upper lobe resection in 2021, s/p recent admission for mechanical fall with facial injury (3/18/23),hypothyroidism presenting to the ED with 1 day history of dizziness admitted to medicine for work up to rule out stroke given risk factors and previous h/o stroke.
Plan:
- Admit to stroke unit with telemetry
- Neuro checks every 4 hours
- Vital signs every 4 hours
- Permissive HTN with goal of SBP 130-160
- MRI brain without iv contrast if negative can be discharged if ambulatory
- Transthoracic echo
- Will obtain Hb A1c, Lipid panel, Vit B12, Folic acid level, Homocysteine, LFTs, TSH
- Continue Eliquis 5mg bid
- Continue Lipitor 40mg qhs
- Start Fluids NS 75mg /hr x12 hrs
Patient Education: Discussed taking appropriate dosing of hypertensive medication. Emphasized importance of continuing Eliquis and Lipitor. Advised to maintain healthy diet and exercise. Discussed return precautions such as dizziness, headache, weakness, numbness, vomiting, slurred speech, or facial drooping.
