History
Identifying Data:
Full Name: YF
Address: N/A
Date of Birth: N/A
Date & Time: 03/15/2011, 11:00am
Location: NYPQ
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “I’ve been very forgetful and confused” x 5 days.
41 y/o right-handed man with 10-pack-year history of smoking, with h/o HTN not on any medications, brought in by EMS presenting to the ED for confusion, disorientation, clumsiness of right hand, and bilateral leg heaviness for 5 days. Girlfriend notes that pt has not been his “usual self.” She states she had been hospitalized for a few days over the weekend, and they had been texting Saturday (3/25/23) and pt texted girlfriend saying that he had seen her in the house that day. Patient did not seem to remember girlfriend was in the hospital. She also reports that pt’s texts became incoherent and pt himself admits to having difficulty texting the words he wanted to, and that his messages were unintelligible. He also endorses picking up a cup and dropping it to the floor, and difficulty walking upstairs due to heaviness in both legs with weakness worse in right leg. Pt also reports he got pulled over while driving the day prior for not realizing he drove down the wrong way on a one-way street. Patient continues to be disoriented today per family member. Denies headache, numbness, chest pain, changes in vision, falls, dizziness, leg pain, recent travel, long car rides, facial droop or slurred speech.
Initial DDx:
TIA
Ischemic Stroke
Intracerebral hemorrhage
Past Medical History:
HTN
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent 2022)
Screening test and results – N/A
Past Surgical History:
No past surgical history.
Denies any blood transfusions.
Medications:
Not on any medications at this time.
Allergies:
NKDA
Family History:
Mother – Stroke at 66 y/o, deceased
Dad – MI at 51 y/o, deceased
Sister – Diabetes
Maternal/paternal grandparents – Deceased at unknown age
Denies family h/o diabetes and cancer.
Social History:
Mr. YF lives with girlfriend and children.
Habits – Admits to being current smoker for past 20 years. Smoking includes cigarettes. Has never used smokeless tobacco. No history of alcohol abuse, denies history of illicit substances. Denies drinking coffee.
Travel – No recent travel.
Diet – He states he 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 – Denies headache or head trauma.
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 –Denies irregular heartbeat, 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 – N/A
Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous –Admits to loss of strength in right hand and weakness in both legs R>L. Admits to moments of confusion and altered mental status. Denies seizures, headache, ataxia, change in cognition.
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: Male 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 156/101 P: 99 beats/min, regular
(L) Seated 153/100
R: 20 breaths/min, unlabored O2 Sat: 95% on room air
T: 37 degrees C (oral)
Height: 71 inches Weight: 108.9 kg BMI: 33.4
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 – Mild ptosis OS. No strabismus, exophthalmos. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/25 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.
Male Genitalia: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.
Anus, Rectum, and Prostate:
No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus.
Neurologic:
Mental status:
Patient is alert and oriented to person, place and time.
Cranial nerves:
II: Visual fields full
III, IV, VI: Pupils 4mm bilaterally, EOMI without nystagmus, no gaze preference, + ptosis left eye
V: V1-V3 intact bilaterally
VII: facial movements symmetric
VIII: hearing intact to finger rub
IX, X: no dysarthria
XI: shoulder shrug 5/5 bilaterally
XII tongue midline
Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 4/5 right lower extremity and 5/5 bilateral upper extremity and left lower extremity, no fasciculations. No abnormal movements.
Cerebellar: Rapid alternative movements, finger to nose intact. Patient deferred testing gait. Negative Romberg. (+) 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: 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: 1
GCS: Glasgow Coma Scale
Eye Opening: Spontaneous
Best Verbal Response: Oriented
Best Motor Response: Obeys commands
Glasgow Coma Scale Score: 15
Modified Fisher:
SAH present on imaging: IVH present in bilateral ventricles
Dysphagia Screen:
Modified Rankin (Modified Rankin Interval: Pre-stroke): Modified Rankin Score: 0
Labs:
BMP
NA 139
K 4.4
CL 106
CO2 20
BUN 16.5
CREATININE 0.99
GLU 109
CA 11.2
ANOINGAP 13
CBC
WBC 13.14
HGB 18.4*
CRIT 53.7*
PLT 395
NEUTP 64.5
LYMPHP 24.40
MONOP 9.7
EOSP 0.20
Hepatic Panel
TP 8.1
ALB 4.6
GLOB 3.5
TBILI 0.5
DBILI 0.1
IBILI 0.4
SGOT 23
SGPT 25
ALK 168*
Coags
PT 13.3*
INR 1.14*
APTT 29.6
Lipid Panel
CHOL 221
HDL 21
TRIG 176.0
Urinalysis
Orange
Turbid
SGUR >= 1.045
PHUR 5.5
PROTUR 100
GLUUR negative
UKETONE negative
UBILI negative
UBLOOD large
BACTUR negative
RBCUR >100
WBCUR 15
SQUAMOUSEC 1
HYALCAST 4
NIUR negative
LEUKU small
Procal <0.06
Respiratory Panel negative
Imaging:
CT Head w/o IV Contrast (3/29/23):
Hypodensity in the right basal ganglia and caudate nucleus with extension to the right corona radiata. Findings are highly suspicious for an age-intermediate (acute to early subacute appearing) cerebral infarct. Findings of paranasal sinus disease.
CTA Head & Neck:
Moderate stenosis involving the supraclinoid right internal carotid artery and high-grade stenosis involving the left cavernous carotid artery. Mild stenosis involving the origin of the left internal carotid artery.
EKG: sinus bradycardia at 58 bmp, no ischemic changes
Differential Diagnosis After:
Stroke
Assessment:
41 y/o right-handed man with 10-pack-years history of smoking with h/o HTN being admitted for acute right ischemic stroke. CT head notable for right acute ischemic basal ganglia, corona radiate and caudate nucleus infarct. CTA head and neck with moderate stenosis of right internal cerebral artery, supraclinoid, and high-grade stenosis of left cavernous internal cerebral artery
Plan:
- Admit to stroke unit
- Place on telemetry
- Obtain Transthoracic echo with bubble study
- Obtain Transthoracic doppler with bubble study
- Obtain MRI brain non-contrast
- Lower extremity bilateral doppler to rule out DVT
- Obtain urine toxicology screen
- Obtain Hemoglobin A1C, folate, vitamin B12, homocysteine, and thyroid function tests,
- Repeat lipid panel
- Allow for permissive HTN with a SBP goal of 130-160, avoid IV hydralizine and hypotension
- Start lipitor 80mg qhs
- Start Aspirin with loading dose of 325mg and then 81mg once daily
- Start DVT prophylaxis with Lovenox
- Neuro check every 4 hours
- Obtain PT and OT evaluation
- Maintain finger stick glucose <150
Patient Education: Discussed importance of follow-up with cardiologist for further eval uation and treatment of hypertension. Advised to eat a heart healthy diet with low salt content, exercise, and losing weight to reduce risk factors. Also advised patient about the need to stop smoking.
