Internal MED H&P

History

Identifying Data:

Full Name: AP

Address: Flushing, Queens

Age: 76

Date & Time: May 20, 2019

Location: New York-Presbyterian/Queens Hospital – Stroke Unit

Religion: Catholic

Nationality: Dominican

Marital Status: Widowed

Source of Information: Interpreter ID # XXXX/Daughter

Source of Referral: New York-Presbyterian Queens Hospital ED

 

Chief Complaint:

HPI: 76 y/o Hispanic F with PMHx: of HTN, HLD (on Pravastatin), and vertigo. PSHx: cholecystectomy, C-section x3. Presents to the ED for evaluation of occipital headache, R sided weakness/numbness, and right facial droop since 5pm yesterday. Patients last known normal just prior to 5pm yesterday (about 25 hours PTA). The headache is constant dull in character and does not radiate. Per daughter the patient also experienced slurred speech and difficulty ambulating one hour after the initial symptoms started around 6pm. Patients reports that she was seen by her PMD a few hours after symptom onset, who advised her to come to the ED for a stroke evaluation. Daughter states the slurred speech and facial droop resolved before ED arrival. At time of examination patient has weakness and decreased sensation to right face/arm/and leg. Denies any hx of stroke, CP, vision changes, SOB, or palpitations. Patients received an NIHSS score of 1, and an ABCD2 score of 5. Pt takes aspirin 81mg daily.

 

Past Medical History:

Past medical illnesses –

HTN x 4 years (well controlled with Amlodipine, Losartan HCTZ, Metoprolol)

HLD x 4 years (well controlled on Pravastatin)

Vertigo x 2 years (no episode x 1 year) on Meclizine

Hospitalized

Vertigo—2017- for syncope workup

Childhood illnesses – Chicken pox when younger. Denies any childhood illnesses.

Immunizations – Up to date with all vaccination, including Pneumococcal and flu vaccine.

Screening tests and results – Screening mammogram (10+yrs ago), benign.

Past Surgical History: Cholecystectomy- more than 40 years ago , C-section x3 -more than 40 years ago

Medications:

Medications:

ASA 81mg 1 tab once a day -primary prevention

Amlodipine 10 mg 1 tab once a day- HTN

Losartan 50mg HCTZ 12.5mg – one tab once a day- indication HTN

Meclizine 1 tab once a day PRN- Indication vertigo

Metoprolol 100mg 1 tab once a day – Indication HTN

Pravastatin 10 mg 1 tab once daily- indication HDL

Allergies:

Denies drug, environmental or food allergies.

Family History:

Paternal Grandfather – pt doesn’t know

Paternal Grandmother – pt doesn’t know

Maternal Grandfather – pt doesn’t know

Maternal Grandmother – pt doesn’t know

Father – deceased at 80 cause unknown

Mother – deceased at age 90 cause unknown

Daughter – 49 well and living

Daughter- 50 well and living

Son-51 well and living

Denies family h/o heart arrhythmia, heart disease, lung disease, CVA, cancer, diabetes mellitus, allergies, asthma, gastrointestinal disease, disease of urinary tract, or psychiatric or nervous disorders.

Social History:

Mrs. AP is a widowed female, living with her daughter. She currently does not work.

Habits – She does not consume any caffeine. Denies smoking cigarettes, drinking alcohol or illicit drug use.

Travel – She denies any recent travel.

Diet – Her diet mostly consists of chicken, fish and vegetables.

Exercise – She walk about 10 blocks 2 times a week to pick up her grandchild from school. Other than that she does not get much exercise. She sleeps about 9 hours each night.

Safety measures – admits to wearing a seat belt.

Sexual hx – She currently is not sexually active.

ROS:

General – Pt c/o R sided weakness. denies recent weight loss or gain, loss of appetite, generalized fatigue, fever or chills, or night sweats.

Skin, and nails – denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus,

Hair- no change in hair texture or distribution.

Head – c/o occipital headache and has a h/o vertigo, denies head trauma.

Eyes – does not wear glasses; denies visual disturbance, lacrimation, photophobia, or pruritus.

Ears – denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/Sinuses –denies nasal congestion, discharge, epistaxis or obstruction.

Mouth and throat – denies bleeding gums, sore tongue, sore throat, mouth ulcers, or voice changes. Last dental exam was 1 year ago.

Neck – denies localized swelling/lumps, stiffness/decreased range of motion.

Breast – denies lumps or pain.

Pulmonary System – denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.

Cardiovascular System – she has h/o HTN, HDL Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal System – denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, abdominal pain, diarrhea, change in bowel habit, hemorrhoids, constipation or melena.

Genitourinary System –denies any urgency, urinary frequency and nocturia; denies flank pain, oliguria, polyuria, dysuria, incontinence. Last GYN exam -does not recall states “it was many years ago”.

Nervous System – c/o occipital headache, weakness, facial droop(resolved), and decreased sensation in right arm/leg and face. Denies seizures, loss of consciousness, sensory disturbances, ataxia, change in cognition/mental status/memory.

Musculoskeletal System – denies pain; denies deformity/swelling, redness, or arthritis

Peripheral Vascular System – denies SOB, intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System –denies any blood transfusions, anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine System – denies polyuria/polydipsia/polyphagia, heat or cold intolerance, goiter, excessive sweating, hirsutism.

Psychiatric – denies depression/sadness, anxiety, obsessive/compulsive disorder, seeing a mental health professional, taking psychiatric medications. 

Physical

General: 76 y/o Hispanic female, AO x3. Patient is well developed, and well groomed. She looks her stated age and doesn’t appear to be in any acute distress.

Vital Signs:

BP: 123/67

Temp: 98.6 F oral

HR: 62 BPM

RR: 16 breaths per min on room air

SpO2: 98%

Height: 153cm

Weight: 71.5 kg

BMI: 30.5

Finger stick glucose: 106 mg/dl

EKG: NSR, no ST changes- ECG WNL

Lab Results:
141 | 97 | 17.4
——————–< 114   Ca: 10.1   Anion Gap: 15
3.8 | 29 | 0.75

WBC: 10.01 / Hb: 15.1 Hct: 43.8 / Plt: 280
PT: 10.8 / PTT: 33.5 / INR: 0.96
Troponin: <0.010

Vitamin B12 level 691 (normal 211-945) MCV

Imaging:

-CT Head/Brian w/o contrast results- Chronic white matter microvascular ischemic changes. (neg for acute process)

-CTA pending

-ECG- NSR, no ST changes, results WNL.

Gen: AOx3, sitting comfortably in bed, in no acute distress

Skin: warm & moist, good turgor. Non-icteric, no cyanosis no lesions noted, no scars, tattoos.

Hair: average quantity, and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout.

ENT: nose patent, mucosa pink and moist, oropharynx clear, Auditory acuity intact to whispered voice AU.

EYES: PERRLA, EOMI, anicteric, no erythema, no discharge

Cardiology: normal S1 and S2 no murmurs or extra heart sounds, noted on auscultation carotid pulses are 2+B/L no bruit noted, no JVD noted.

Respiratory: chest non-tender to palpation, Lat to AP diameter 2:1 with symmetrical rise, Respirations unlabored/no use of accessory muscles noted no evidence of trauma, no rales, crackles wheezing, or rhonchi noted on exam.

Gastroenterology: Soft, non-distended, non-tender, normal BS X4, no Guarding, no Rebound

Musculoskeletal: mild FROM, with no swelling, deformity, or erythema, no tenderness, or pain on palpation.

Neurology: A&O x3, mild decreased sensation to right face/arm/leg, no focal neuro deficit. normal strength

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 palpable adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Rectal and Genital exam was not performed due to lack of privacy in ED. (over-crowded bed placed without curtain)

Differentials:

TIA

CVA

ICH

B12 deficiency

Hypoglycemia

Assessment:

76 y/o Hispanic F with PMHx: of HTN, HLD, and vertigo. PSHx: cholecystectomy, C-section x3. Presents to the ED for evaluation of occipital headache, R sided weakness/numbness, and right facial droop since 5pm yesterday. Patients last known normal just prior to 5pm yesterday (about 25 hours PTA). The headache is constant dull in character and does not radiate. Per daughter the patient experienced slurred speech and difficulty ambulating one hour after onset of initial symptoms. Patients reports that she was seen by her PMD a few hours after symptom onset, who advised her to come to the ED for a stroke evaluation. Daughter states the slurred speech and facial droop resolved before ED arrival. At time of examination patient has weakness and decreased sensation to right face/arm/and leg. Patient’s NIHSS score =1. CT head w/o contrast was negative no sign of ICH. Labs are WNL no sign of infectious process. B12 levels are normal. Finger stick glucose 106 mg/dl.

Pt’s ABCD2 score is 5 therefore, hospital observation for further TIA workup may be needed.

Plan:
#Suspected cerebrovascular accident/transient ischemic attack

– NIH SS = 1, ABCD2 score of 5 – Admit to stroke unit for further w/up

– Q 4hrs neuro and vital sign checks.

– Do not give TPA. Patient is not a tpa candidate, as pt presents outside of timeframe for tpa (last known normal about 25 hours PTA).

– Place patient on telemetry monitoring
– Permissive hypertension: during the first 24 hours after onset of symptoms, will hold medications unless BP> 220/120
– Ordered CT head with no contrast -was negative for acute process
– Ordered and performed CT head and neck with contrast- pending results
– Will order MRI brain without contrast

– Order Carotid Doppler

– Repeat EKG, cardiac monitoring to r/o cardio embolic stroke
– Order Transthoracic echo
– follow lipid panel, A1C, TSH
– Administer aspirin, statin
– Make patient NPO- order speech and swallow evaluation -follow recommendation
– Order Physical therapy consult- follow recommendations

– Order Neuro consult
– Check serial cardiac enzymes, HA1c and fasting lipid profile, TSH, HbA1c, lipid panel, TSH, B12/folate, homocysteine
– Give ASA 325 mg X1 now and 81 mg daily starting tomorrow.
– Start Lipitor 80 mg daily, adjust statin dose per lipid panel result

-Place patient on fall precaution
-Evaluate and treat any hypotension. Can use IVF w/NS if needed

-Start DVT ppx with heparin subQ
– Order PT/OT consult/evaluation.
– Supply patient and patient family with stroke education booklet.

#HTN: (well controlled on meds last BP noted 123/67)

Permissive hypertension: hold BP meds until MRI results.

BP monitoring q 4 hrs

#HLD (well controlled with pravastatin)

Start Lipitor (Atorvastatin) 80 mg daily during hospital stay

#Vertigo (last episode a year ago)

Give Meclizine if symptomatic

#BMI 30.5 (obese)

Order Nutritionist consult for patient before discharge.

Provide patient and family with the following information:

• Explain the patient may have suffered a TIA, which occurs when there is a temporary blockage of blood flow to the brain.
• Symptoms include weakness on one side of the body, vision problems, and slurred speech. These are transient and often resolve within 24 hours.
• TIA’s despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke.
• TIA (time-based, lasting <24 hours) and minor ischemic stroke are associated with a high early risk of recurrent stroke.
• Since studies show that stroke risk in the first two days after TIA is approximately 4 to 10 percent, we use risk stratification models that combine information from brain imaging, neurovascular imaging, and presumed TIA etiology in addition to the clinical ABCD²score in effort to improve the accuracy of stroke risk prediction after TIA.
• Immediate evaluation and intervention after a TIA, or minor ischemic stroke reduces the risk of recurrent stroke.
• For patients who present with TIA or minor ischemic stroke, we recommend implementation of appropriate diagnostic evaluation and stroke prevention treatment without delay, preferably within one day of the ischemic event.
• Risk factor management is appropriate for all patients with ischemic stroke or TIA, and most patients should be treated with all available risk reduction strategies.
• The current viable strategies include blood pressure reduction, statins, antiplatelet therapy, and lifestyle modification, including smoking cessation.