Age: 79.0
Sex: F
Vaccine: COVID19-2
Symptoms: Visual impairment, White blood cell count normal
Clinical narrative: Hospital Admission H&P of 11/21:  Patient:     Date of Birth:             PCP: MD Code Status: FULL Service:  Hospitalist Admitting Physician: Dr. Date of Admission: 11/21/2022   Chief complaint: Left eye blindness   Transferred from: Ophthalmology History of Present Illness:   Source: chart review, the patient, and Dr.    Patient is a 79 y.o. female with PMH of Alzheimer's/dementia, COPD, hypercholesterolemia, s/p cataract surgery x3 yr s ago, presents to ER from ophthalmology clinic after developing acute onset of left-sided blindness occurring 3 days ago.  Reported lasted for about a minute.  Otherwise she denies any associated symptoms such as headache, dizziness, change in speech, any new lateralizing weakness, chest pain, word finding, facial drooping, nausea vomiting, chest pain or palpitations.  She was eval by ophthalmology did not find any abnormality on examination including visual field deficit, hemorrhagic retinopathy, papilledema, retinal occlusion.   In ER Vitals: Temp 98.1, pulse 60, RR 20, BP 130/70, mid 90s on RA Imaging: CTA head and neck: No acute intracranial hemorrhage or mass, no high-grade stenosis occlusion or aneurysm EKG: None Labs: CBC, troponin, CMP, INR, CRP, TSH WNL Txt in ER: Aspirin, Plavix 1 L NS bolus     Medical History Past Medical History: Diagnosis Date ? Allergic rhinitis   ? Alzheimer's disease, unspecified (HCC) (HCC)   ? Arm laceration 08/2020 ? Arthritis   ? Constipation   ? COPD (chronic obstructive pulmonary disease) (HCC) (HCC)   ? Cough   ? Dementia in other diseases classified elsewhere with behavioral disturbance   ? Diverticulosis large intestine w/o perforation or abscess w/bleeding   ? Dyssynergia   ? Esophageal stricture   ? Heart burn   ? History of recurrent UTIs   ? Hypercholesteremia   ? Lung nodule   ? Memory problem   ? Migraine   ? Osteoporosis   ? Rectal sphincter incontinence          Surgical History Past Surgical History: Procedure Laterality Date ? CARDIOVASCULAR STRESS TEST   2016   negative ? COLON SURGERY       Diverticulitis= removal of 12 inches.  ? HIP SURGERY Right 2017 ? HIP SURGERY Left 2022 ? HYSTERECTOMY     ? ROTATOR CUFF REPAIR Left   ? ROTATOR CUFF REPAIR Right   ? SINUS SURGERY   2017        Family History Problem Relation Age of Onset ? Leukemia Mother   ? Brain cancer Father   ? Lung cancer Father   ? Osteoporosis Sister          reports that she quit smoking about 5 years ago. Her smoking use included cigarettes. She started smoking about 59 years ago. She has a 35.00 pack-year smoking history. She has never used smokeless tobacco. She reports that she does not drink alcohol and does not use drugs.     Medications:     Current Facility-Administered Medications:  ?  sodium chloride 0.9 % bolus 1,000 mL, 1,000 mL, intravenous, Once, MD   Current Outpatient Medications:  ?  budesonide-formoteroL (SYMBICORT) 160-4.5 mcg/actuation inhaler, Inhale 2 puffs 2 (two) times a day Rinse mouth with water after use. Do not swallow., Disp: 1 g, Rfl: 4 ?  imipramine (TofraniL) 25 mg tablet, Take 1 tablet (25 mg total) by mouth nightly (Patient not taking: Reported on 10/18/2022), Disp: 30 tablet, Rfl: 11 ?  denosumab (Prolia) 60 mg/mL syringe syringe, , Disp: , Rfl:  ?  polyethylene glycol (GLYCOLAX) 17 gram/dose powder, , Disp: , Rfl:  ?  celecoxib (CeleBREX) 200 mg capsule, every 12 hours, Disp: , Rfl:  ?  benzonatate (TESSALON) 100 mg capsule, Take 200 mg by mouth 3 (three) times a day as needed for cough, Disp: , Rfl:  ?  ipratropium (ATROVENT) 21 mcg (0.03 %) nasal spray, Administer 2 sprays into each nostril every 12 (twelve) hours, Disp: , Rfl:  ?  azelastine (ASTELIN) 137 mcg (0.1 %) nasal spray, Administer 2 sprays into each nostril 2 (two) times a day, Disp: , Rfl:  ?  predniSONE 1 mg tablet, Current dose 5 mg daily. Decrease by 1 mg every 2 weeks. (Patient not taking: No sig reported), Disp: 140 tablet, Rfl: 0 ?  albuterol HFA (PROVENTIL HFA;VENTOLIN HFA) 90 mcg/actuation inhaler, Inhale 2 puffs every 6 (six) hours as needed for wheezing, Disp: 1 Inhaler, Rfl: 6 ?  melatonin 10 mg capsule, Take by mouth, Disp: , Rfl:  ?  gabapentin (NEURONTIN) 300 mg capsule, Take 300 mg by mouth 2 (two) times a day  , Disp: , Rfl:  ?  atorvastatin (LIPITOR) 10 mg tablet, Take 10 mg by mouth daily, Disp: , Rfl:  ?  BROMPHENIRAMINE MALEATE ORAL, Take 1 capsule by mouth 2 (two) times a day 6mg capsule, Disp: , Rfl:  ?  dicyclomine (BENTYL) 20 mg tablet, Take 20 mg by mouth nightly, Disp: , Rfl:  ?  amitriptyline (ELAVIL) 10 mg tablet, Take 10 mg by mouth nightly as needed  , Disp: , Rfl: 1 ?  acetaminophen (TYLENOL) 500 mg tablet, Take 1,000 mg by mouth every 6 (six) hours as needed for pain scale 1-3/10, Disp: , Rfl:  ?  wheat dextrin (BENEFIBER SUGAR FREE) 3 gram/4 gram oral powder, Take 2 g by mouth daily as needed, Disp: , Rfl:  ?  fluticasone propionate (FLONASE) 50 mcg/actuation nasal spray, Administer 2 sprays into each nostril 2 (two) times a day as needed  , Disp: , Rfl: 3 ?  donepezil (ARICEPT) 10 mg tablet, Take 20 mg by mouth nightly  , Disp: , Rfl:  ?  conjugated estrogens (PREMARIN) vaginal cream, Insert 0.5 g into the vagina 2 (two) times a week  , Disp: , Rfl:  ?  multivitamin (THERAGRAN) tablet tablet, Take 1 tablet by mouth daily., Disp: , Rfl:  ?  omeprazole (PriLOSEC) 20 mg capsule, Take 20 mg by mouth daily.  , Disp: 90, Rfl: 0   Allergies Allergen Reactions ? Codeine Other (see comments)     Severe constipation ? Ciprofloxacin       Other reaction(s): rash ? Sulfa (Sulfonamide Antibiotics) Other (see comments)     Stomach upset       Review of Systems  Constitutional:  Negative for diaphoresis and fever.  HENT:  Negative for congestion, drooling, rhinorrhea and sore throat.   Eyes:  Positive for visual disturbance. Negative for pain and discharge.  Respiratory:  Negative for cough, shortness of breath and wheezing.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for abdominal pain, diarrhea, nausea and vomiting.  Genitourinary:  Negative for dysuria, frequency and urgency.  Musculoskeletal:  Negative for back pain and neck pain.  Skin:  Negative for color change.  Neurological:  Negative for dizziness, speech difficulty, numbness and headaches.  Hematological:  Does not bruise/bleed easily.  Psychiatric/Behavioral:  Negative for confusion.         Findings:   PHYSICAL EXAM: Temp:  [36.9 °C (98.4 °F)] 36.9 °C (98.4 °F) Heart Rate:  [66-77] 77 Resp:  [14-22] 22 SpO2:  [90 %-95 %] 94 % BP: (145-168)/(65-101) 158/101     Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is normal weight. She is not ill-appearing.  HENT:     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No oropharyngeal exudate or posterior oropharyngeal erythema.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Normal range of motion. No rigidity.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.      Labs: CBC with Platelet:   Lab Results Component Value Date   WBC 7.2 11/21/2022   HGB 11.9 11/21/2022   HCT 35.4 11/21/2022   PLT 272 11/21/2022   RBC 4.04 11/21/2022   MCV 87.5 11/21/2022   MCH 29.4 11/21/2022   MCHC 33.6 11/21/2022   RDW 13.1 11/21/2022   MPV 7.4 11/21/2022   Comp:  Lab Results Component Value Date   NA 140 11/21/2022   K 3.9 11/21/2022   CL 102 11/21/2022   CO2 30 11/21/2022   BUN 13 11/21/2022   CREATININE 0.81 11/21/2022   GLUCOSE 86 11/21/2022   CALCIUM 9.2 11/21/2022   PROT 7.0 11/21/2022   ALBUMIN 4.1 11/21/2022   AST 14 11/21/2022   ALT 9 11/21/2022   ALKPHOS 85 11/21/2022   BILITOT 1.28 11/21/2022     Lab Results Component Value Date   TROPHS 6.7 11/21/2022   TROPHS1HR 9.8 05/07/2021   HSDELTA1 2.9 05/07/2021     Lab Results Component Value Date   TSH 3.208 04/13/2021     Lab Results Component Value Date   INR 1.1 11/21/2022   PT 12.8 (H) 11/21/2022             Imaging: CT angiogram head and carotid neck   Result Date: 11/21/2022 Exam: Contrast-enhanced CT angiography of the head and neck from 11/21/2022 at 1842 Clinical History:  acute thromboembolic stroke Comparison(s): CT head 4/12/2017 Technique: During the bolus intravenous administration of 100 cc of Isovue-370 helical axial imaging was performed through the head and neck . Two millimeter axial reconstructions, 2-D and 3-D volume MIP reformations, 3-D volume MIP reformations with dual energy technique plaque subtraction, 3-D volume rendering, and curved multiplanar reformats were constructed and reviewed. Dose Reduction Technique: Dose reduction technique utilized; automatic/anatomic modulation of X-ray tube current (Auto mA). Findings: CTA of the head:  Anterior circulation: No occlusion, high-grade stenosis, aneurysm or vascular malformation. Posterior circulation: No occlusion, high-grade stenosis, aneurysm or vascular malformation. Brain: No evidence of hemorrhage, mass, shift, or extra axial fluid collection. The gray-white matter differentiation is maintained. The ventricles are normal in size and morphology. Bones and orbits: Normal. Soft tissues: Normal. Paranasal sinuses and mastoid air cells: Clear. CTA of the neck: Aortic Arch: Normal. Left carotid:  No occlusion, high-grade stenosis, or vascular injury. Right carotid:  No occlusion, high-grade stenosis, or vascular injury. Vertebrobasilar:  No occlusion, high-grade stenosis, or vascular injury. Soft tissues: Normal. Bones: No fracture.    IMPRESSION: 1.  No acute intracranial hemorrhage or mass effect. 2.  There is no high-grade stenosis, occlusion or aneurysm in the head or neck.     Problem list: Principal Problem:   Stroke-like symptom Active Problems:   Migraine without aura and without status migrainosus, not intractable   Memory loss   COPD (chronic obstructive pulmonary disease) (HCC) (HCC)     Assessment & Plan: 1. Strokelike symptoms/left eye blindness: Concern for TIA, routine work-up including CBC, CMP, CTA head and neck unremarkable.  Loaded with aspirin and Plavix, seen by neurology in ER.  Recommended stroke work-up including MRI, PT/OT/SLP, echo, TSH, A1c, lipid panel.  Allow for permissive hypertension, labetalol as needed with parameters.  Check ESR and CRP 2. Hx of Migraine: possible symptoms of ocular migraine. Check ESR, CRP.  3. Hyperlipidemia: Lipitor 4. Hx dementia: Aricept 5. Hx COPD/asthma: Continue Symbicort, Claritin/Allegra 6. GERD: PPI 7. Hx pulmonary nodule: Followed by pulmonary, follow-up CT chest 3/2023 8. Remote history of smoking   DVT Prophylaxis:  Lovenox   Code Status: FULL   This was reviewed with the patient/family/caregiver at the time of admission.   Anticipated length of Stay: <2 midnight stay   Spent approximately 70 minutes in total admitting patient, >50% time spent face to face in discussion with patient, ER physician, reviewing chart/records, coordination of care, history gathering, physical exam, admitting orders and answering questions to patient's/family satisfaction.