Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram head normal, Creatinine renal clearance decreased, Glomerular filtration rate decreased, Glucose urine absent, Haematocrit decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 07, 2023 01:33   Verified By: MD on November 07, 2023 01:33   Encounter Info: Hospital, Observation, 11/06/23 -     * Final Report *  Document Has Been Revised        Chief Complaint   Left-sided weakness  History of Present Illness/Subjective     This is an 85-year-old female with history of hypothyroidism and B12 deficiency presenting with left-sided weakness.  Left-sided weakness, upper and lower extremity, started today around 5 PM.  By the time she had arrived to the emergency department, symptoms have nearly resolved.  Denies numbness, paresthesias, visual changes, headache.   CT angiography was obtained demonstrating diffuse plaque, moderate at its maximum severity, but no large vessel obstruction or large volume stenosis.  Patient has no known history of atrial fibrillation.   Systolic blood pressure is markedly elevated in the 190-208 range, mild sinus tachycardia.  On my physical examination at this time, if there is any residual left-sided weakness, it is negligible.  Cranial nerves are intact.  Patient is alert oriented and cooperative.    No history of stroke, heart attack, peripheral arterial disease.  White blood cell count normal, mild normocytic anemia, coags are good.  Mild hyperglycemia.   Head CT shows no acute abnormality.   Blood pressure markedly elevated, ischemia with reactive hypertension.   Additionally with a diagnosis of multiple sclerosis although this does not appear to be consistent with an acute flare.  Review of Systems     Review of systems negative except as noted above.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.7 °C (Oral)  TMIN: 36.0 °C (Oral)  TMAX: 36.7 °C (Oral)  BP: 193/94  HR: 59 (Monitored)  RR: 16  SpO2: 98%  Oxygen Therapy: Room air  WT: 84.10 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    84.1 kg    11/06/23    Patient Height  Current Height:    158 cm    11/06/23        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI, cranial nerves intact ENMT:  Moist oral mucosa Neck:  Supple, non-tender, no bruit, no JVD Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment I do not appreciate any significant asymmetry in upper or lower extremity strength, wrist grip.  Sensation appears to be symmetric and intact.  Cranial nerves appear to be intact.  No abnormal cerebellar findings on examination.  No pronator drift present.. Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Acute stroke due to ischemia   I63.9   No large vessel occlusion and outside any window for treatment, particularly with markedly improving and nearly resolved neurologic deficits.  Would consider this a high risk TIA, permissive hypertension, dual antiplatelet therapy, high-dose statin.  We will check A1c, lipid panel, obtain transthoracic echocardiogram.  Telemetry.  Nursing dysphagia screening, PT and OT to assess tomorrow.   2. Blood pressure elevated without history of HTN   R03.0   Permissive hypertension, will not treat unless systolic blood pressure greater than 210.   3. B12 deficiency   E53.8   Check levels   4. GERD (gastroesophageal reflux disease)   K21.9   PPI   5. Prediabetes   R73.03   Check an A1c   6.  MS - noted, MR pending tomorrow   SCDs   Full code  Code Status   None Recorded   Chronic Problem List    Acid reflux  Anemia  Arthritis  B12 deficiency  Corn of toe  Degenerative joint disease of left ankle and foot  Dysphagia  Encounter for long-term current use of medication  GERD (gastroesophageal reflux disease)  Hypothyroidism  Ingrown toenail  Injury of left ankle and foot  Left ankle instability  Myelodysplastic syndrome  Onychomycosis  Osteoarthritis  Osteoporosis  Peroneal tendinitis of left lower leg  Personal history of breast cancer  Prediabetes  Sinus tarsitis of left foot  Sprain of left foot  Procedure/Surgical History  ?Colonoscopy (01/18/2022) ?D&C ?Gallbladder ?Hysterectomy     Medications   Home Medications (10) Active  anastrozole 1 mg oral tablet 1 mg = 1 Tablet, Orally, Daily  Calcium 500 + D3 , BID  luspatercept 1 mg/kg, Subcutaneous, Every 3 Weeks  magnesium oxide 400 mg oral tablet 800 mg = 2 Tablet  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  PreserVision   Prolia 60 mg/mL subcutaneous solution 60 mg, Subcutaneous, Every 6 Months  Suprep Bowel Prep Kit oral liquid See Instructions, as directed  Synthroid 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, Daily  Vitamin B-12 1000 mCg/ml injectable solution 1,000 mCg, IM, Every Month  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/06/23 00:00:00 TO 11/07/23 01:33:35  aspirin, Tab, Chewable, 324 mg, Orally, ONCE, (1 DOSE 11/06/23 20:43:00)  ondansetron (Zofran), Injection, 4 mg, IV Push, ONCE, (1 DOSE 11/06/23 20:16:00)  PRN Medications (0600 - 0559) from 11/06 - 11/07  None Reported  Allergies   sulfa drugs (rash)  ferrous sulfate  Social History    Electronic Cigarette/Vaping   E-Cigarette Use Never.   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Family history is unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.1 k/cumm (11/06/23 19:03:00)  RBC: 3.72 million/cumm (11/06/23 19:03:00)  Hgb: 11.4 GM/dL Low (11/06/23 19:03:00)  Hct: 34.4 % Low (11/06/23 19:03:00)  MCV: 92 fL (11/06/23 19:03:00)  MCH: 30.7 pg (11/06/23 19:03:00)  MCHC: 33.2 GM/dL (11/06/23 19:03:00)  RDW: 16.4 % High (11/06/23 19:03:00)  Platelet: 299 k/cumm (11/06/23 19:03:00)  MPV: 9.2 fL (11/06/23 19:03:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (11/06/23 19:03:00)  Potassium SerPl QN: 4 mmol/L (11/06/23 19:03:00)  Chloride SerPl QN: 104 mmol/L (11/06/23 19:03:00)  Carbon Dioxide SerPl QN: 23 mmol/L (11/06/23 19:03:00)  Anion Gap: 8 mmol/L (11/06/23 19:03:00)  BUN SerPl QN: 24 mg/dL High (11/06/23 19:03:00)  Creatinine SerPl QN: 1.02 mg/dL (11/06/23 19:03:00)  Estimated GFR (CKD-EPI, no race): 54 mL/min/1.73m2 Low (11/06/23 19:03:00)  Estimated CRCL (CG): 41 mL/min Low (11/06/23 19:03:00)  Glucose SerPl QN: 141 mg/dL High (11/06/23 19:03:00)  Calcium Total SerPl QN: 9.7 mg/dL (11/06/23 19:03:00)  Alkaline Phos SerPl QN: 58 Units/L (11/06/23 19:03:00)  ALT SerPl QN: 11 Units/L (11/06/23 19:03:00)  AST SerPl QN: 15 Units/L (11/06/23 19:03:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (11/06/23 19:03:00)  Total Protein SerPl QN: 6.9 GM/dL (11/06/23 19:03:00)  Albumin SerPl QN: 4 GM/dL (11/06/23 19:03:00)  Troponin-I High Sensitivity: 8 ng/L (11/06/23 19:03:00)  Gluc-Strip, POC: 132 mg/dL High (11/06/23 19:34:00)  Coagulation:  PT: 11.8 seconds (11/06/23 19:03:00)  INR: 1.04 (11/06/23 19:03:00)  aPTT: 25.9 seconds (11/06/23 19:03:00)  Urine Studies:  Color: Light-Yellow (11/06/23 19:52:00)  Clarity: Clear (11/06/23 19:52:00)  Specific Gravity: 1.024 (11/06/23 19:52:00)  pH: 8 (11/06/23 19:52:00)  Protein: NEGATIVE (11/06/23 19:52:00)  Glucose: Normal (11/06/23 19:52:00)  Ketones: TRACE. Abnormal (11/06/23 19:52:00)  Bilirubin: NEGATIVE (11/06/23 19:52:00)  Hgb Ur: NEGATIVE (11/06/23 19:52:00)  Nitrite: NEGATIVE (11/06/23 19:52:00)  Urobilinogen: Normal (11/06/23 19:52:00)  Leukocyte Esterase Ur: NEGATIVE (11/06/23 19:52:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (11/06/23 19:36:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/06/23 19:36:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/06/2023 19:29 - CT Head W/o IV Contrast  IMPRESSION: 1. No acute intrarenal hemorrhage or mass effect.2. See above.Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the ER Reading Room.    11/06/2023 19:29 - CTA Head/Neck W/IV Contrast  IMPRESSION:CTA neck:1. Coarse calcified plaques cause a roughly 50-60 percent diameterstenosis of the proximal right ICA by criteria year.2. No definite evidence of significant focal stenosis or occlusion involving the rest of the cervical carotid or vertebral arteries.CTA head:1. Patchy calcified plaques cause variable narrowing along thevisualized portions of both internal carotid arteries, with up tomoderate stenosis of the left ophthalmic ICA segment.2. No definite evidence of significant focal stenosis  or  occlusionsaccular  involving the rest of the major intracranial arterialvasculature.-Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/06/2023 19:31 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 11/07/23 01:33  ________________________________________________________ MD  Electronically Signed on 11/07/23 01:41  ________________________________________________________ MD