Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Sternotomy, Transient ischaemic attack, Troponin I, Vertebral artery stenosis, White blood cell count normal
Clinical narrative: Document Type: History and Physical; Document Subject: History & Physical Note Performed By: MD on July 22, 2022, 01:56 EST Verified By: MD on July 22, 2022, 01:56 EST Encounter Info: Emergency, 07/21/22 - 07/22/22  * Final Report * History of Present Illness/Subjective. This is a 90-year-old male with hypertension, hyperlipidemia, seasonal allergies, diabetes on metformin who presents on 7-22-2022 brought in with slurring of speech and is being transferred as we do not have any beds here. He was recently here just yesterday 7-21-2022 with similar presentation with slurred speech although resolved on its own (and is now resolved yet again on it sounds).  Work-up done yesterday was unremarkable for anything acute and it was recommended that he go for TIA work-up (because again, did not have any beds available) however they chose to leave AMA instead. With a left, throughout most of the day today, 7-22-2022, he laid in bed and began slurring his words at around 10:00 PM so his wife got scared and brought him back and would now like to seek treatment. In the ER CT head done again today showing chronic findings and suggesting MRI. CTA done just yesterday showing no acute findings, numerous scattered lacunar infarcts, moderate atherosclerosis stenosis at the origin of the vertebrals, moderate intracranial ICA atherosclerosis with moderate right and left-sided stenosis.  EKG showing bifascicular block with a QTC in the 470s.  No marked ST deviations.  Without chest pain. Patient will answer my questions however he is quite sarcastic, so it is tough for me to tell if he is joking with me or if he actually means some of his responses.  Family at bedside is laughing so I believe he may be like this quite regularly.  States that he was having some difficulty speaking so he came into the hospital because "his wife made him" he states he feels fine, states he did not want to even come into the hospital in the first place, but his wife made him. Review of Systems 12 point review of systems completed and is negative except for what is listed above Physical Exam/Objective Vital Signs (most recent and range for last 24 hours) Temp (CEL)  36.2 (36.2-36.2)   Temp (FAHR)  97.2 (97.2-97.2) , BP  126/66 (108-174)/(56-82) , HR  69 (69-79) , RR  20 (18-20) , O2Sat  99 (96-99) Neurologic (most recent and range for last 24 hours) GCS  15 (15-15) Patient Weight; Current Daily Weight: 90.1 kg  07/21/22; Patient Height; Current Height:      177.8 cm      07/21/22 On exam he is awake alert and oriented x3, at first he thought it was 2033 however I believe he was just joking with me and then quickly changed his answer to 2022 with a smile.  Neurologically he is completely intact.  No issues with dysphonia, no aphasia at the time of my evaluation.  He has a large midline sternotomy scar that is present.  Movement is intact in all 4 extremities.  Mucous membranes appear moist.  Rest of his evaluation is noncontributory. Assessment/Plan TIAs; Slurred speech, resolved; Hypertension; Hyperlipidemia; Diabetes. He is presenting again with slurred speech just as he did a few days prior however all of this has since resolved. He is being transferred over for further TIA work-up. This will include carotid Dopplers, echo, MRI, telemetry and may need to be sent out on a Holter monitor: I spoke with someone this evening prior to transfer, and they are able to provide all of those services today. They are already very anxious to have his work-up completed so they can go home, I encouraged their patience to remain at the hospital to complete work-up. ???????Physical therapy and Occupational Therapy and speech will be ordered. Resume aspirin, statin, I am adding Plavix now given severity of atherosclerosis seen on imaging.  I did not speak with neurology this evening, may be able to do a video conference with them during normal hours in the morning (no urgent need for me to speak with them overnight). Resume home antihypertensives once med rec is done. Insulin sliding scale. Lives at home with his wife. ???????They wish to be DO NOT RESUSCITATE/DO NOT INTUBATE, patient agrees, wife agrees. Code Status None Recorded Chronic; Problem List Anemia; Arthritis; Barrett's esophagus; Benign essential HTN; Burning pain; Chronic diarrhea; Chronic GERD; Diabetes mellitus; Diabetic neuropathy; Diverticulitis; Drug-induced diarrhea; Dysphagia; Fatigue; Gastric ulcer; Health care maintenance; History of heart attack; Hyperlipemia; Hypertension; ITP (idiopathic thrombocytopenic purpura) Left shoulder pain; Left shoulder pain; Neuropathy; Onychogryphosis; Onychomycosis; Osteoarthritis of left shoulder Osteoarthritis of left shoulder; Osteoarthritis, generalized; Pancreatic cyst; Pancreatitis; Pancreatitis, chronic; Pre-ulcerative calluses; Rheumatoid arthritis of multiple sites with negative rheumatoid factor; Schatzki's ring of distal esophagus; Seborrheic dermatitis; Shingles (herpes zoster) polyneuropathy; Thrombocytopenia; Procedure/Surgical History; EGD - Esophagogastroduodenoscopy (04/16/2021); Esophagogastroduodenoscopy (07/07/2020) Colonoscopy (07/23/2019); Esophagogastroduodenoscopy (07/23/2019); egd w dilation (08/21/2018); egd (04/21/2015); Appendectomy; cabg; CABG - Coronary artery bypass graft; Cholecystectomy; Echocardiogram stents; Surgical History Internal 04/16/2021; EGD Balloon Dilate Less 30mm, MD; Medications; Home Medications (12) Active; Active Scheduled Inpatient Medications; None Reported; One-Time Medications Given 07/21/22 00:00:00 TO 07/22/22 01:55:51; None Reported; PRN Medications (0600 - 0559) from 07/21 - 07/22; None Reported; Social History Alcohol; Denies Electronic Cigarette/Vaping; Never- Substance Abuse; Denies Tobacco Tobacco Use: Former smoker, quit more than 30 days ago. Family History Lung cancer. Sister and Brother. _____________________________ MD