Age: 38.0
Sex: M
Vaccine: COVID19
Symptoms: VIth nerve paralysis, Vertebral artery hypoplasia
Clinical narrative: ED notes: 39 y.o. male with no significant medical history brought by EMS for dysarthria, RT arm weakness, and RT facial droop beginning at 2:05pm today. Sx acute onset, severe, constant, and have not occurred previously. Pt was driving just prior to symptom onset when he called his mother stating he did not feel well at 2:05pm. Upon arriving home, mother noticed he was dysarthric and called 911. EMS noted facial droop, arm weakness, dysarthria, and gaze palsy and transported him to the hospital. Initial glucose by EMS 110. Pt denies headache, recent head trauma, history of brain hemorrhages or prior stroke.  PMH: None, PSH: None, Allergies: NKDA, Tobacco: Denies, ETOH: Social, Drugs: Denies Pt AAOx3, bib from home for weakness and facial droop. Stroke alert called en route. As per report, pt was driving home at 2 pm when he started to feel ""weird"". Pt called his wife and was able to drive himself home. Upon arrival at his house he ""collapsed"" on the couch and his wife noticed right-sided facial droop and weakness, more prominent on the right side. Upon arrival to ED pt appears pale and weak. R sided facial droop and right arm and right leg weakness noted. Dr. at bedside. Stroke alert called in ED.  Hr noted to be in the 40s. As per wife, pt is an athlete 5/4/21 Critical Care Notes: Neurology- No hx of neurological disease but does have family history of blood clotting disorder in maternal uncles and cousins (factor 2 and factor 5 but unclear specific diagnosis)- Patient presented with R sided weakness, R facial droop, dysarthria, double vision, R CN 6 palsy; no prior history of similar events- CT brain negative for acute abnormaility - CTA brain/perfusion showed no significant stenosis, occlusion, aneurysm, no perfusion abnormality- MRI brain showed small acute ischemic infarct in ventromedial L thalamus and chronic bilateral cerebellar lacunar infarcts- Patient showing improvement in symptoms s/p tPA- Repeat CT showed new mild hypoattenuation suggesting evolving acute infarction with no bleed, herniation, mass effect, or midline shift- Echo with bubble study revealed patient PFO, No DVT on LE US- Lipid profile WNL, tox screen neg, RPR neg- Neuro checks per unit protocol- Check ANCA, Anti cardiolipin, anti thrombin III, antiphospholipid Ab, Factor V Leiden, Protein C and S, ANA, FTA, A1c; Dr. (H/O) consulted- ESR elevated- DAPT per neuro- DSA with NIR today  Cardiology- Hx of sinus bradycardia: Patient is athletic, works out regularly. Had previous cardiac evaluation with no significant findings- EKG showing borderline 1st degree AV block- Troponin neg- BP well controlled - MAP goal >65mmHg- 2D echo with bubble study revealed patent PFO, No DVT on LE US Heme/Onc- CBC unremarkable - No active bleeding- Transfuse if Hgb < 7- DVT prophylaxis SCDs, patient ambulatory- No DVT on LE US- Workup as above for blood clotting disorders given stroke in otherwise young healthy patient with family history of clotting disorders- H/O consulted, pending eval 5/9/21 Neurology Note: Overall neurological assessment remains stable and unchanged overnight. Double vision on the right eye stable, improving as per patient's report. Will recommend to continue with DAPT as ordered. Follow up with neurology as an outpatient in 2-4 weeks. Follow up with Cardio as well. Ok to discharge patient home as per Neurolgy standpoint. 1. Left ventromedial thalamic CVA. 2. PFO - S/P closure 5/7/2021. 3. Congenital hypoplastic left VA, basilar trunk. 4. Remote cerebellar lacunar infarcts. 5. Family history of Factor V Leiden, factor II. PLAN: 1. Ok to discharge patient home as per neurology standpoint. 2. Continue ASA 81 mg and Plavix 75 mg Daily. 3. Follow up with neurology as an outpatient in 2- 4 weeks. 4. Follow up with Cardio as per their recommendations. 5. Medical management as per IM.