Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin normal, Headache, Laboratory test abnormal, Lymphocyte count, Lymphocyte percentage
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: MD on November 11, 2021 18:34   Verified By: MD on November 12, 2021 04:35   Encounter Info: Hospital, Emergency, 11/11/21 - 11/11/21    * Final Report *        Basic Information   No qualifying data available.   Chief Complaint  Headache (Complaint of), Vision changes (Complaint of)  History of Present Illness     Supporting Nursing Comments:  PT presents to the ED with complaints of vision changes x1 month and a slight headache that he noticed 3 days ago. The patient states that he has been monitoring his BP and it has been elevated over the past few days.    HPI: patient complains of blurred vision on and off for a month and a slight right retro-orbital headache headache which radiates to the vertex. The patient states the headache has been intermittent but was more persistent today. He monitored his blood pressure today and noted it was elevated. His blood pressure was 180/96 on arrival. The patient does not wear glasses except for over-the-counter reading glasses. He states he has felt mentally foggy the last day or 2 but denies any paresthesia or focal weakness.  Review of Systems     Constitutional: No fevers, no chills,  no sweats Eyes: + Changes in vision, blurred vision Ears, Nose, Mouth, Throat: No ear pain, no nasal congestion, no sore throat Respiratory: No shortness of breath, no cough, no wheeze Cardiovascular: No chest pain, no palpitations, no edema Gastrointestinal: No abdominal pain, no nausea, no vomiting, no diarrhea, no constipation Genitourinary: No frequency, no urgency, no dysuria, no hematuria Hematologic/Lymphatic: No bruising, no enlarged lymph nodes Allergic/Immunologic: No hives Endocrine: No cold intolerance, no heat intolerance, no polyuria, no polydipsia Musculoskeletal: No arthralgia, no myalgia Skin: No rash, no pruritus Neurological: + Headache, no focal weakness, no numbness some "brain fog" Psychiatric: No anxiety, no depression  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.8 DegC  Heart Rate:       85 bpm  Resp Rate:       18 br/min  BP #1:       180 / 96 mmHg  SpO2 (%):       97 %  O2 Device:       Room air     Weight KG: 122 kg     Constitutional:  + Mild distress,  well-nourished Eyes:  PEERL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion, no meningismus 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,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  Medical Decision Making     The patient is currently taking lisinopril and amlodipine. He is not taking hydrochlorothiazide or olmesartan          Re-Assessment  Blood pressure improved at time of discharge 140/78  Condition     Stable  Counseled: Patient on findings, diagnosis and plan. Patient voices understanding.  Disposition: Discharged to home  Assessment/Plan       1. Headache   R51.9     2. Hypertension not at goal   I10     3. Blurred vision   H53.8     4. Hyperglycemia due to diabetes mellitus   E11.65     Orders:   cloNIDine, 0.1 mg, = 1 Tablet, Orally, TID, PRN blood pressure 180/110 or greater, Maintenance, Dispense: 15 Tablet, Refills: 0, Total Refills: 1, 11/11/21 22:14:00, Pharmacy: pharmacy, 1 Tablet Orally TID,x5 Days,PRN:blood pressure 180/110 or grea...  Auto Diff  CBC w/Differential  Comp Metabolic Panel  CT Head W/O IV Contrast  CTA Head/Neck W/IV Contrast  Discharge Patient  Electrocardiogram  Peripheral IV Insertion  Troponin-I High Sensitivity   Patient Education   Blurred Vision  High Blood Pressure, Established, Out of Control, in the ED  Self-Care for Headaches  Follow Up        With  When  Contact Information        MD, OPH Within 3 to 5 days Surgical Eyecare  Additional Instructions: Cafll for appointment           MD, CAR Within 3 to 5 days  Additional Instructions: Call for appointment        Chronic Problem List    No qualifying data  Procedure/Surgical History  ?tooth extraction (08/08/1994)  Medications  Home Medications (3) Active amLODIPine/hydroCHLOROthiazide/olmesartan 10 mg-12.5 mg-40 mg oral tablet 1 Tablet, Orally, Daily aspirin 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, Daily metFORMIN 500 mg, Orally, BID  Medication Administration   Given  cloNIDine 0.1 mg oral tablet, 0.1 mg, Orally  Allergies   No Known Medication Allergies  Social History    Alcohol   Current, Beer, Liquor, 1-2 times per month   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never Smoker.    Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  11/11/21 18:47  6.8        RBC  11/11/21 18:47  5.10        Hgb  11/11/21 18:47  15.0        Hct  11/11/21 18:47  43.9        MCV  11/11/21 18:47  86        MCH  11/11/21 18:47  29.5        MCHC  11/11/21 18:47  34.3        RDW  11/11/21 18:47  14.5        Platelet  11/11/21 18:47  322        MPV  11/11/21 18:47  7.1        Neutrophils %  11/11/21 18:47  53        Lymphocytes %  11/11/21 18:47  38        Monocytes %  11/11/21 18:47  6        Eosinophils %  11/11/21 18:47  3        Basophils %  11/11/21 18:47  1        Absolute Neutrophil  11/11/21 18:47  3.6        Absolute Lymphocyte  11/11/21 18:47  2.5        Absolute Monocyte  11/11/21 18:47  0.4        Absolute Eosinophil  11/11/21 18:47  0.2        Absolute Basophil  11/11/21 18:47  0.1          Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  11/11/21 18:47  137        Potassium SerPl QN  11/11/21 18:47  3.9        Chloride SerPl QN  11/11/21 18:47  102        Carbon Dioxide SerPl QN  11/11/21 18:47  26        Anion Gap  11/11/21 18:47  9        BUN SerPl QN  11/11/21 18:47  13        Creatinine SerPl QN  11/11/21 18:47  1.04        Estimated GFR (CKD-EPI)  11/11/21 18:47  77        Estimated CRCL (CG)  11/11/21 18:47  95        Glucose SerPl QN  11/11/21 18:47  159  High        Calcium Total SerPl QN  11/11/21 18:47  9.7        Alkaline Phos SerPl QN  11/11/21 18:47  55        ALT SerPl QN  11/11/21 18:47  25        AST SerPl QN  11/11/21 18:47  15        Bilirubin Total SerPl QN  11/11/21 18:47  0.3        Total Protein SerPl QN  11/11/21 18:47  7.5        Albumin SerPl QN  11/11/21 18:47  4.2        Troponin-I High Sensitivity  11/11/21 18:47  <3      Diagnostic Results  CT Head W/o IV Contrast    11/11/21 20:00:35  IMPRESSION:   1. Age-related volume loss and findings suggestive of mild small  vessel disease.   2. No definite evidence of acute intracranial hemorrhage, significant  intracranial mass effect or depressed calvarial fracture.      PHYSICIANS RADIOLOGY REPORT   EXAM: CTA Head/Neck W/IV Contrast   DATE: 11/11/2021 19:57 hours   INDICATION: R vertex and retrorbital headache x 3 days,?brain fog? blurry vision,h/o HTN, current BP 180/96 ,type II DM; R vertex and  retrorbital headache x 3 days,?brain fog?blurry vision, h/o HTN,  current BP 180/90 type II DM   COMPARISON: None   Technique:   After IV contrast administration, contiguous axial images were  obtained through the head and neck. Multiplanar 2-D reformats and  thick slab 3-D MIP reconstructions were obtained.  80 mL of Isovue 370 was administered intravenously.   FINDINGS:   CTA neck:   There is a four-vessel arch, with the innominate artery, the left  common carotid artery, the left vertebral artery left subclavian  artery originating discretely from aortic arch.   Innominate artery shows no significant compromise. The bilateral  common carotid and the bilateral cervical internal carotid arteries  show no significant compromise.   The right vertebral artery is dominant. The bilateral cervical  vertebral arteries show no significant focal stenosis along their  course.   No definite evidence of a discrete intimal flap to suggest an acute  dissection of the cervical carotid or vertebral arteries.   There are disc osteophyte complexes which contribute to cause mild  central canal stenosis at the C5-C6 and C6-C7 levels.     CTA head:   There are patchy calcified plaques along the cavernous and clinoid  segments of both internal carotid arteries, which cause mild  narrowing. The major branches of the bilateral anterior cerebral and  middle cerebral arteries show no significant focal stenosis. There  is a patent anterior communicating artery.   There are patent bilateral posterior communicating arteries. The  major branches of the bilateral posterior cerebral arteries show no  significant focal stenosis. The basilar artery and the V4 segments of  both vertebral arteries show no significant focal stenosis.   No definite evidence of saccular aneurysm formation involving the  major intracranial arterial vasculature.   The dural venous sinuses grossly appear patent.   IMPRESSION:   CTA neck:   No definite evidence of significant stenosis, occlusion or acute  dissection involving the cervical carotid or vertebral arteries.   CTA head:   1. There are patchy calcified plaques along the cavernous and clinoid  segments of both internal carotid arteries, which cause mild  narrowing.   2. No definite evidence of significant stenosis or occlusion  involving the major intracranial arterial vasculature.     Thank you for consulting our team of subspecialty radiologists at  Radiology. Healthcare providers wishing to discuss  this case further can contact the Neuroradiology Reading Room.  For after-hours or emergency department cases, please  call.   Electronically Signed by:     Signed By: MD     ************************************************** CTA Head/Neck W/IV Contrast    11/11/21 20:00:35  IMPRESSION:   1. Age-related volume loss and findings suggestive of mild small  vessel disease.   2. No definite evidence of acute intracranial hemorrhage, significant  intracranial mass effect or depressed calvarial fracture.      PHYSICIANS RADIOLOGY REPORT   EXAM: CTA Head/Neck W/IV Contrast   DATE: 11/11/2021 19:57 hours   INDICATION: R vertex and retrorbital headache x 3 days,?brain fog? blurry vision,h/o HTN, current BP 180/96 ,type II DM; R vertex and  retrorbital headache x 3 days,?brain fog?blurry vision, h/o HTN,  current BP 180/90 type II DM   COMPARISON: None   Technique:   After IV contrast administration, contiguous axial images were  obtained through the head and neck. Multiplanar 2-D reformats and  thick slab 3-D MIP reconstructions were obtained.  80 mL of Isovue 370 was administered intravenously.   FINDINGS:   CTA neck:   There is a four-vessel arch, with the innominate artery, the left  common carotid artery, the left vertebral artery left subclavian  artery originating discretely from aortic arch.   Innominate artery shows no significant compromise. The bilateral  common carotid and the bilateral cervical internal carotid arteries  show no significant compromise.   The right vertebral artery is dominant. The bilateral cervical  vertebral arteries show no significant focal stenosis along their  course.   No definite evidence of a discrete intimal flap to suggest an acute  dissection of the cervical carotid or vertebral arteries.   There are disc osteophyte complexes which contribute to cause mild  central canal stenosis at the C5-C6 and C6-C7 levels.     CTA head:   There are patchy calcified plaques along the cavernous and clinoid  segments of both internal carotid arteries, which cause mild  narrowing. The major branches of the bilateral anterior cerebral and  middle cerebral arteries show no significant focal stenosis. There  is a patent anterior communicating artery.   There are patent bilateral posterior communicating arteries. The  major branches of the bilateral posterior cerebral arteries show no  significant focal stenosis. The basilar artery and the V4 segments of  both vertebral arteries show no significant focal stenosis.   No definite evidence of saccular aneurysm formation involving the  major intracranial arterial vasculature.   The dural venous sinuses grossly appear patent.   IMPRESSION:   CTA neck:   No definite evidence of significant stenosis, occlusion or acute  dissection involving the cervical carotid or vertebral arteries.   CTA head:   1. There are patchy calcified plaques along the cavernous and clinoid  segments of both internal carotid arteries, which cause mild  narrowing.   2. No definite evidence of significant stenosis or occlusion  involving the major intracranial arterial vasculature.     Thank you for consulting our team of subspecialty radiologists at  Radiology. Healthcare providers wishing to discuss  this case further can contact the Neuroradiology Reading Room.  For after-hours or emergency department cases, please  call.   Electronically Signed by:     Signed By: MD  EKG  11/11/21, 18:11  72bpm. NSR, Normal E\kg       Signature Line Electronically Signed on 11/12/21 04:35  ________________________________________________________ MD