Age: 45.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Full blood count, Gait disturbance, Haemoglobin decreased, Hemiparesis, Hypertension
Clinical narrative: This is 45 y.o. male with past medical history of type 2 diabetes, hypertension, hyperlipidemia, GERD, and history of right-sided stroke in April 2021.  He was admitted to hospital 6/6/2021 with worsening left-sided stroke symptoms after working out in the heat.  MRI showed similar appearing infarct in the right hemi-pons, with neurology thinking he was having worsening of his previous stroke.  Pt was admitted to rehab 6/10/2021 for acute inpatient rehabilitation related to right hemi-pons stroke. While at rehab, the patient made functional progress within the multi-disciplinary team. The patient's course at was complicated by uncontrolled diabetes and HTN, for which the medicine team was consulted.  The patient's family/ friends were unable to provide appropriate supervision and physical assistance needed for a safe discharge. Due to this, placement was found at Facility. The patient was discharged on 6/23/21 with recommendations for ongoing therapy at facility.    Primary Rehabilitation Diagnosis:  Stroke Rehab Course:  Please refer to the individual therapy discipline consult and discharge summaries for further details. PT- Per PT note 6/22 "Transfer & Bed Mobility Sit to/from Stand - FIM: Modified independent Sit to/from Stand - Method: From standard seat height;w/ Assistive device;w/o Assistive device Bed to/from W/C - FIM: Stand by assist Bed to/from W/C - Method: Standing pivot w/o assistive device Gait Distance (m): 20 m ( x 4) Device: Narrow based quad cane Assistance: Minimal assist Gait Quality (General): Slowed;Shuffling (step-to pattern) Gait Quality (Right side):  (decreased step length) Gait Quality (Left side):  (decreased knee extension in stance) Wheelchair Mobility Type of Chair: Standard Distance (m): 30 m ( x 3) Obstacles Course:  (asphalt ) Wheelchair Propulsion - FIM: Modified Independent (household exemption) Wheelchair Propulsion - Method: Right UE;Right LE Environment: Level surface;Ramp;Threshold (ramps in parking lot. )" - PT recommended              OT- Per OT note 6/22 "Activities of Daily Living Grooming: Supervision/Stand by assist Grooming Comments: standing at sink, 1 handed strategies Toileting: Supervision/Stand by assist Toileting Comments: close SBA for clothing mgmt   Functional Mobility Sit to/from Stand - FIM: Minimal assist (75% patient effort) Sit to/from Stand - Method: From standard seat height;w/o Assistive device Toilet Transfer - FIM: Minimal assist (75% patient effort) (CGA) Bed to Bathroom- FIM: Minimal assist (75% patient effort) Bed to Bathroom- Method: Wide base quad cane   Cognition / Visual Perception Mental Status: Alert;Oriented x 3;Cooperative;Follows 1 step direction" - OT recommended        SLP- Per SLP note 6/22 "ongoing mild-moderate cognitive-linguistic deficits in attention and reasoning as well as minimal dysarthria s/p R pontine infarcts.  Pt 100% intelligible in conversation but reports decreased articulatory precision with fatigue. Less tangential this date but did report increased fatigue.  Continues with frequent complaints of limitations however takes little initiative to improve his performance and then rationalizes the difficulties he is having. " - SLP recommended               Therapeutic Recreation-Provided education on substance use/abuse, community re-integration, intimacy, and pedestrian safety. Clinical in 3-6 months     Malnutrition Malnutrition Characteristics Energy Intake: Adequate Weight loss:: None Body fat:: WNL Muscle mass:: WNL Fluid accumulation:: None Malnutrition Diagnosis: No Weight: 96.8 kg (213 lb 6.4 oz) Wt Change from Previous: 0 Kg Wt Change from Admit: -5.18 Kg % Wt Change from Adm: -5.07 % Ideal Body Wt (IBW) Male (kg): 75.3 kg     #Nutrition: cont carb consistent diet regular consistency, thin liquids #Bladder: Continent.  RN to do timed toileting q2h while awake. #Bowels: cont bowel program of miralax prn. Last BM 6/22 #Skin:  No pressure injuries noted upon admission or discharge.   #Pain management: tylenol 650 q4hr prn #Sleep/agitation:  Melatonin 3 mg qHS PRN insomnia   Medical Co-morbidities:   # Small R hemipons stroke: Originally had a stroke in this area in April with near full recovery but 2nd episode on 6/6 after possible heat exhaustion showed worsening of the area with more L side weakness noted compared to prior. -continued ASA 81 plus plavix 75 daily  (scheduled at 12PM per pt request to reduce pill burden in AM) for now. Aspirin to stop on Jul 9th and Plavix to continue indefinitely. -Continue to secondary stroke prevention as below for diabetes, hypertension, hyperlipidemia -PT/OT/SLP at facility   #DM2:  -Blood glucose checks QIDACHS, high-dose sliding scale insulin, hypoglycemia protocol -SSI: 10 units + 2u/50>150 TID AC -Lantus 35 units qHS and 40 units qAM per internal medicine -Metformin 1000 mg BID -Dapagliflozin 10mg q24h at noon (started 6/14) - scheduled at noon per pt request of not taking so many meds in the AM. -BG 70 - 174 last 24 hrs (6/23). Has had intermittent episodes of hypoglycemia in the afternoons   #HLD: continued on atorvastatin 20, fenofibrate 48 mg daily DC'd per internal medicine due to elevated creatinine.   #HTN - amlodipine 10 mg daily - carvedilol 25 mgBID (increased 6/18 per internal medicine) -HCTZ 25 mg  -Lisinopril 40mg daily -Continue K-Dur 20 mEq BID WM -SBP 140s- 150s last 24 hrs (6/23)   #GERD: continue omeprazole 20mg daily (home medication).   #allergies; continued cetirizine 10mg q12h (6am and pm per pt request) along with flonase 2 sprays BID PRN and montelukast 10mg qhs   #Erectile dysfunction -Possibly related to stroke -We will have patient follow-up with PCP to discuss ED medications if needed in the future   #History of hypokalemia -Possibly related to hypertension medications -Potassium within normal limits 6/16 -Continue K-Dur 20 mEq BID WM -Recheck as outpatient -Potassium within normal limits 6/21   #Acute Kidney Injury.  - Pt to continue PO fluid intake - Creatinine 1.31 on 6/21 - Recheck as outpatient with PCP   #Anemia: Unclear etiology, possibly iatrogenic from blood draws - Hgb trending up to 11.8 on 6/21 - Recheck as outpatient with PCP   #Risk for anemia/infection/electrolyte abnormalities: Pt had at least weekly BMP/CBC. Foll #VTE prophylaxis: lovenox 40 daily until fully ambulatory or 8 weeks from stroke ~ 8/1/21. Continue to assess  #CODE STATUS: DNR per discussion with patient   RECOMMENDATIONS AND FOLLOWUP:  -PCP within 7 days of discharge - PA -pt to make this appointment as it is outside of area -PM&R within 4-6 weeks of discharge if going to a facility - Neurology follow up in 3 months  Thursday Sept 9, 10am Hospital - Ongoing PT/ OT/ SLP at facility - Outpatient neuropsych referral     PHYSICAL EXAMINATION AT DISCHARGE: BP 150/88 (Cuff Location: Right Arm)  | Pulse 83  | Temp 36.8 °C (98.2 °F) (Temporal)  | Resp 18  | Ht 1.803 m (5' 11")  | Wt 96.8 kg (213 lb 6.4 oz)  | SpO2 98%  | BMI 29.76 kg/m²    General: Alert and cooperative, NAD. Sitting up at edge of bed.  HEENT: Normocephalic, Sclera non-icteric, no rhinorrhea, wears glasses.  Cardiac: Normal S1 and S2.  R/R/R. No edema noted bilateral LEs.  Respiratory: CTA A/P bilaterally. Breathing comfortably on room air. Gastrointestinal: Bowel sounds present, abdomen soft, nondistended, nontender. Musculoskeletal:  LUE: SA 3/5, EE 2/5, EF 2/5, WF 1/5, FF 2/5 LLE: HF 4/5, KE 3/5, PF 0/5, DF 0/5 RUE and RLE strength 5/5 Extremities:  Calves soft, non-tender bilaterally. Neurological: Speech fluent/ comprehensible. Skin: Exposed skin warm, dry  Psych: affect pleasant   Interpreter Needed: No