Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Serum ferritin normal, Swelling face, Thiopurine methyltransferase, Vitamin B12 normal, Vitamin D
Clinical narrative: MYASTHENIA GRAVIS. SEE NOTES FROM DR. AND HOSPITAL STAY FROM 1/6/22 TO 1/15/2022. CONTINUATION WEAKNESS FROM MYASTHENIA GRAVIS, EVEN AFTER THREE MONTHS. Progress Notes by Dr at 1/14/2022 3:53 PM. Neurology Inpatient Consult, Patient: (65 year old). Referring Provider: Refer to consult order in electronic medical record. ASSESSMENT:   65 year old male presented to Hospital on 1/6/2022 with a week of dysarthria and dysphagia presenting with some funny sensation on his tongue and mild swelling of the lower lips. His symptoms does fluctuate and better in the early morning which might suggest a neuromuscular junction disorder. No clinical history to suggest botulism or Eaton-Lambert syndrome.  Differential diagnosis include ischemic stroke.  CT of the head was unremarkable. BNP was normal.  D-dimer is 1.55. Magnesium is 2.6. Sed rate and CRP were normal. COVID-19 was not detected. No leukocytosis. Vitamin D is 23. Serum iron and ferritin were normal. TSH was low. And it was negative. Vitamin B12 and folic acid were normal. Serum IgA level was normal. CPK is 220. Brain MRI: 1.  Normal examination of the brain. Head CT: 1. No acute intracranial hemorrhage. 2.  There is metallic streak artifact from patient's dental amalgam and there is beam hardening artifact at the frontal lobes from the adjacent frontal calvarium.This likely accounts for hypoattenuating foci at bilateral frontal lobes. However, ischemia cannot be entirely excluded given this artifact particularly at the left frontal lobe. If patient has a focal neurologic deficit or there is clinical suspicion for acute cerebrovascular accident, brain MRI would be most sensitive for further evaluation. CT of the chest: 1. No mediastinal mass or adenopathy. No thymoma identified. 2. There is either admixing of contrast with unopacified blood versus partially visualized thrombus within the main portal vein extending into the superior mesenteric vein. This could be more accurately assessed with CT scan of the abdomen and pelvis with contrast. 3. Mild elevation of the left hemidiaphragm with bibasilar atelectasis, left-greater-than-right. 4. Cardiomegaly with some moderate atherosclerotic ossific changes of coronary arterial vasculature. 5. Main pulmonary artery is distended suggestive of pulmonary arterial hypertension. 6. Fusiform aneurysmal dilatation of the proximal aortic arch measuring 3.3 cm in largest diameter with ectasia of the ascending aorta, distal aortic arch and descending thoracic aorta. 7. Bilateral renal cysts. Impression: Dysarthria/dysphagia most likely from bulbar myasthenia gravis. Unclear history of angioedema. Hypertension. Obstructive sleep apnea. BPH. Colonic polyp status post colectomy. Restless leg syndrome, Anxiety disorder. Subocclusive thrombus of the left central portal vein and main portal vein. Nearly occlusive thrombus within the central superior mesenteric vein. PLAN: Change Decadron to 4 mg twice daily p.o. start slow taper. Continue Mestinon 60 mg 3 times a day. Institute GI and DVT prophylaxis while on steroid and closely monitor for any complication of steroid therapy. Follow-up myasthenia antibodies and thio purine methyltransferase. Hospitalist to follow-up portal and mesenteric venous thrombosis. Monitor for any medication that might worsen his myasthenia. No further suggestion at this time. Will sign off. Please call if needed. Follow-up with outpatient neurology in 4 to 6 weeks. I have personally reviewed/visualized the patient's images, as documented above. I have personally reviewed the patient's labs, procedure and ancillary testing as listed above. Impression, plan and suggestions was discussed with the patient/family/caregivers.  Questions and concerns were discussed and addressed. This note was created in part using a speech-recognition software. Dysarthria and dysphagia. Answered questions and rediscussed plan at length with Patient, Daughter. DIAGNOSTIC TESTING SUMMARY: Pending Lab and Radiology Results, Order Current Status, MG Evaluation Adult In process. Thiopurine Methyltransferase (Activity Profile), RBC In process, Thiopurine Methyltransferase (Activity Profile), RBC In process, Resulted Testing: (MRI/CT/XR, EEG, EMG, CSF, Cardiac, Labs). SUBJECTIVE:  Chief Complaint/Reason for Consult: Dysarthria and dysphagia. Informant(s): Patient, Daughter, Care Team/Chart. History of Present Illness: Patient is a 65 y.o. male who was admitted because of abnormal sensation of the tongue while eating salad about a week ago. He described numbness of the tongue and lips. He also developed some slurred speech especially when he gets tired or talks for long periods of time. He denies any recent infection or change in medications.  He had a recent colectomy for colonic polyps. No history of malignancy. No history of limb weakness, numbness, or incoordination. No head injury, seizures, confusion, TIA or stroke. His symptoms fluctuate during the last several days. Nurses notice his speech is much better in the early morning. He was initially diagnosed to have angioedema but he never has any swelling of the lips or tongue. He was given Benadryl and steroid. January 11 patient is awake and alert. He received his first dose of pyridostigmine around 1:15 PM. Around 20 minutes later, he described his speech has improved dramatically.  He claims he is able to move his tongue around without any difficulty. He denies any recurrent swelling. He has no limb weakness or fatigability. Preliminary barium swallow showed that he can tolerate liquid diet. NGT was deferred for now. Patient unable to lay still for brain MRI because of the sensation of dyspnea. He has history of anxiety disorder and restless leg syndrome. His serum iron was normal. Dr. spoke with me yesterday and informed me that he never had any lips or tongue swelling. Nurse practitioner who saw him describes some left facial swelling around 24 to 48 hours of admission. January 12 patient is awake and alert. He transition from liquid diet to soft mechanical diet. His speech remains fluent and spontaneous. Except for fatigue and malaise he has been doing well and tolerating pyridostigmine. He denies any side effects of the medication. He is remains apprehensive about MRI.  Blood pressure 145/95.  He is afebrile. January 13 patient is awake and alert. He tolerated the oral Mestinon. He denies any increased salivation but has been having loose stool since his colectomy. He is able to walk independently to the bathroom by himself. Last night he describes some heaviness of his head. No ptosis or recurrent dysarthria and dysphagia. He thinks he can tolerate laying down for CT of the chest. We discussed diagnostic study for a thymoma. Blood pressure 147/82. He is afebrile. Electrolytes were normal. Glucose is 158. Creatinine is normal. January 14patient continues to be stable neurologically. He even was able to have a brain MRI which did not show any acute stroke. He continues to tolerate Mestinon and steroid.  CT of the chest showed no thymoma although an incidental thrombus on the portal and mesenteric veins were noted. He denies any abdominal symptoms. His colonic polyps were found incidentally during colonoscopy. He has no hepatic symptoms. Past medical history include hypertension, BPH, restless leg syndrome, colonic polyps status post colectomy, loose stools, anxiety disorder. Family history is positive for stroke. No alcohol, tobacco, or recreational drug use. Review of Systems: All systems reviewed and negative except pertinent positives and negatives documented in the History of Present Illness. History: Past Medical History: Diagnosis. Date, Abdominal adhesions, AK (actinic keratosis), Anxiety, Benign prostatic hyperplasia with nocturia. 11/17/2021, Bilateral renal cysts, Boil, leg, BPH (benign prostatic hyperplasia), Colon polyp, Complication of anesthesia, stopped breathing during surgery and changed to general anesthesia, Cutaneous skin tags, Daytime somnolence, Diverticulosis, Edema, Elevated glucose, Elevated PSA, Facet degeneration of lumbar region, Fatigue, GERD (gastroesophageal reflux disease), Gynecomastia, History of kidney stones, Hyperlipidemia, Hypertension, Low back pain, Neoplasm of uncertain behavior of cecum, Obesity, OSA on CPAP, compliant with CPAP, Primary hypertension, 11/17/2021, Sciatica, Sciatica of left side, getting cortisone injections. Sinusitis, Snoring, Spinal cord cysts, Spondylolisthesis, grade 1, Swallowing disorder, Thrombocytopenia, Urine frequency, Venous insufficiency (chronic) (peripheral), Well adult exam, Wheeze. Past Surgical History: Procedure, Laterality Date, ADENOIDECTOMY, APPENDECTOMY, BIOPSY PROSTATE, BUNIONECTOMY, Right CATARACT EXTRACTION, BILATERAL, CATARACT EXTRACTION, BILATERAL, Bilateral, cataract surgery, CHOLECYSTECTOMY, COLECTOMY LAPAROSCOPIC RIGHT, Right 11/17/2021, Procedure: LAPAROSCOPIC TO OPEN RIGHT COLECTOMY;  Service: Colorectal, COLONOSCOPY, N/A, 0/9/2020. Procedure: COLONOSCOPY  with Polypectomy; Service: Gastroenterology, COLONOSCOPY, 2015 COLONOSCOPY, 2020 polyp, COLONOSCOPY, N/A, 4/23/2021. Procedure: COLONOSCOPY;  Service: Colorectal, kidney stones, TONSILLECTOMY, Social History, Socioeconomic History, Marital status: Married, Tobacco Use, Smoking status: Former Smoker, Quit date: 1983.   Years since quitting: 39.0, Smokeless tobacco: Never Used, Vaping Use, Vaping Use: Never used. Substance and Sexual Activity, Alcohol use: Yes. Comment: occasionally, Drug use: Never. Family History, Problem, Relation, Age of Onset, Breast cancer, Maternal Aunt, Breast cancer, Paternal Aunt, Colon polyps, other, Stroke Mother, Migraines Mother, Osteoporosis Mother, Obesity Father, Stroke Maternal Grandmother, Stroke Paternal Grandmother, Heart disease, Maternal Grandfather, Additional History Comments: None. Allergies: Hydrochlorothiazide. HOME Medications: Prior to Admission medications, Medication, Sig, Start Date, End Date, Taking Authorizing Provider, XANAX 0.25 MG tablet. Take 0.25 mg by mouth daily as needed 6/29/20 Historical Provider, MD, Excedrin Extra Strength 250-250-65 mg per tablet, Take 1 tablet by mouth every 6 (six) hours as needed for pain. Historical Provider, MD, TENORMIN 100 MG tablet, 150 mg. 06/29/20. Historical Provider, MD, CARDURA 8 MG tablet, 6/29/20 Historical Provider, MD, PRILOSEC 40 MG capsule V. 6/29/20 Historical Provider, MD. Spironolactone (ALDACTONE) 25 MG tablet, 25 mg 2 (two) times a day. 6/30/20 Historical Provider, MD. HOSPITAL Infusions: Sodium chloride 0.9 %. HOSPITAL Scheduled Medications: Cholecalciferol (Vitamin D3)  1,000 Units, Oral, Daily, DexAMETHasone, 4 mg, Oral, BID with meals. Followed by [START ON 1/18/2022] DexAMETHasone, 4 mg, Oral Daily with breakfast. Followed by  [START ON 1/25/2022] DexAMETHasone, 2 mg, Oral, Daily with breakfast. Followed by [START ON 2/1/2022] DexAMETHasone, 1 mg, Oral, Daily with breakfast. Followed by, [START ON 2/8/2022] DexAMETHasone, 0.5 mg, Oral, Daily with breakfast, Doxazosin, 8 mg, Oral, Nightly, Enoxaparin (LOVENOX) injection, 40 mg, Subcutaneous, Daily, Famotidine, 20 mg, Oral Nightly, Furosemide, 40 mg, Oral, Daily, Metoprolol Tartrate, 50 mg, Oral, BID, Pyridostigmine, 60 mg, Oral, Q8H SCH, Sodium Chloride (PF), 5 mL, Intravenous, Q8H SCH. HOSPITAL PRN Medications: Acetaminophen, HydrALAZINE, Hyoscyamine, Iopamidol, Ipratropium-AlbuteroL, Metoprolol, NalOXone **AND** Notify physician **AND** Naloxone, Ondansetron **OR** Ondansetron, OxyCODONE, Saline lock IV **AND** sodium chloride (PF) **AND** sodium chloride (PF) **AND** sodium chloride 0.9 %. OBJECTIVE: Physical Examination: BP 114/74 (BP Location: Left arm, Patient Position: Sitting)|Pulse 98|Temp 97.7 °F (36.5 °C) (Oral)|Resp 28|Ht 5' 8"|Wt 117.8 kg (259 lb 11.2 oz)| SpO2 89%| BMI 39.49 kg/m². Patient is awake and alert. Neck is supple. No carotid bruit. Heart rate and rhythm is regular. Pulses are 2+ symmetrically. Patient is oriented. Attention and comprehension were intact. Speech is fluent and spontaneous. Language is intact. Follow simple commands. Pupils are 4 mm equally reactive to light. No ptosis, nystagmus, or visual field cuts. Face is symmetrical and facial sensation is intact. Hearing is grossly intact. Palate moved symmetrical upward. Positive shoulder shrug. Tongue is midline. Gross strength in the upper and lower extremity were 5/5. Normal muscle tone and bulk. No muscle fasciculations. Gross sensory is intact to pinprick, vibration, light touch, and proprioception. No tremors or abnormal movements. Finger to nose test was normal. Deep tendon reflexes are symmetrical. No ankle clonus. Toes are downgoing to plantar stimulation.