Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Ataxia, Basilar artery stenosis, Blood thyroid stimulating hormone, Brain natriuretic peptide normal, Computerised tomogram head
Clinical narrative: HBS Discharge Summary      ID:     Date of Admission:  9/24/2023    Date of Discharge:  9/26/2023    Primary Care Physician:  MD   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/27/2023 to 9/27/2023.       Issues to be Addressed in Follow-up: 1) out-pt cardiac monitor 2) compliance with dual antiplatelets and any possible adverse effects   Reason for Hospital Admission (Admitting Diagnosis):  TIA   HPI on admission:  Pt is a 68 Y  male with a history of diabetes mellitus, hypertension, hyperlipidemia, sleep apnea, BPH presents with slurred speech and ataxia. Patient was traveling back from trip, while on the plane he had difficulty standing up from his seat at 9am with slurred speech per wife, it resolved 30 minutes later. Lasted approximately a few minutes. After he got off the flight he had another episode with difficulty walking and slurred speech while at baggage claim at 1pm. He checked his blood glucose and it was approximately 180s. His symptoms subjectively resolved. He denies smoking or alcohol use. Denies visual changes, fever, shakes, chills, nausea, vomiting. He was recently on a cruise ship and has had viral upper respiratory infection with one episode of loose stool. Upon arrival to NIHSS score was 1 (1 point for limb ataxia). CT head negative. Case was discussed with Neurology Dr who recommended MRI/MRA and observation.    Hospital Course: Pt is a 68 Y  male with history of diabetes, hypertension, dyslipidemia, OSA, and BPH, presented with slurred speech and ataxia, found to have TIA and COVID-19 positive.  NIHSS score in ED was 1, ABCD2 score 3. CT head negative for acute intracranial process. MRI/MRA showed focal severe stenosis of the proximal basilar artery. Echocardiogram showed EF 60-65%, grade 1 diastolic dysfunction.  Throughout the admission, patient remained on room air with minimal symptoms. Patient was able to ambulate without assistance. Patient's discharge medication regimen was discussed with neurology (Dr), recommended dual antiplatelet therapy with Asprin and Clopidogrel for 6 months, followed by monotherapy with Clopidogrel. Patient expressed strong desire to go home. Patient was found safe for discharge. Prior to discharge, e-consult for 30-day out-pt cardiac monitor was placed and patient rec'd his monitor prior to leaving the hospital. Patient was instructed to follow-up with his PCP within the next week. Patient voiced understanding and agreed with the plan.   Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 09/26/23 1100 98.4 °F (36.9 °C) Oral 62 130/70 18 98 % RA 09/26/23 0741 98.2 °F (36.8 °C) Oral 57 130/72 18 94 % RA 09/26/23 0329 98.3 °F (36.8 °C) Oral 63 136/76 16 96 % CPAP 09/25/23 2358 ? ? 61 ? ? 96 % CPAP 09/25/23 2344 98.3 °F (36.8 °C) Oral 61 133/75 16 96 % RA 09/25/23 1930 98 °F (36.7 °C) Oral 75 136/77 18 97 % RA       Physical exam General appearance - alert, well appearing, and in no distress Mental Status - alert, oriented x 3 Chest - clear to auscultation, no wheezes, rales or rhonchi Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs Abdomen - soft, nontender, nondistended, no masses or organomegaly Neurological - motor and sensory grossly normal bilaterally Extremities - no clubbing, cyanosis or edema Skin - warm and dry     Hospital Course By Problem: Patient Active Hospital Problem List:  TRANSIENT CEREBRAL ISCHEMIA (9/24/2023)  ATAXIA (9/24/2023)   SLURRED SPEECH (9/24/2023)   - NIHSS 1 in ED. ABCD2 score 3   - CT head negative, EKG showed no arrhythmia   - Asprin 81 mg and Lipitor 10 mg   - Lipid panel within acceptable limit (5/2023)   - Monitor on telemetry   - Echocardiogram (9/25/23): EF 60-65%, grade 1 diastolic dysfunction   - MRI/MRA head: no acute intracranial abnormality, irregularity with focal severe stenosis of the proximal basilar artery    - TSH 1.1   - Patient will need 30-day holter monitor on discharge   - Given MRA findings, after consulting with neurologist (Dr) started Plavix in addition to Aspirin. Neurologist recommended dual antiplatelet for 6 months followed by Plavix alone   COVID-19 POSITIVE   - COVID-19 positive   - Chest x-ray negative for consolidation   - On room air   - Enhanced respiratory and contact precausions   - Continue to monitor respiratory status closely   - No indication to start Remdesivir at this point    - Tessalon Perles and Guaifenesin   DM 2 (2/13/2020)   - hA1c 7.4 (8/2023)   - home regimen: NPH 18 units in the evening, Victoza 1.2 mg daily subq, metformin 1000 mg BID   - Continue NPH 18 units in the evening and Victoza   - Sliding scale insulin, hypoglycemia protocol, adjust insulin regimen to maintain blood glucose between 140-180   - diabetic diet   HTN (HYPERTENSION) (6/2/2020)   - Continue home Losartan-Hctz 100-12.5 mg and Amlodipine 10 mg daily   - BNP within normal limit   HYPERLIPIDEMIA    - Continue Lipitor 10 mg daily   SEASONAL ALLERGIC RHINITIS (5/1/1977)   - Continue home Claritin 10 mg daily   SLEEP APNEA (6/25/2020)   - CPAP at night   BPH (BENIGN PROSTATIC HYPERPLASIA) (5/3/2022)   - Not on any medication   - Monitor for urinary symptoms     Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) TRANSIENT CEREBRAL ISCHEMIA   ? ATAXIA   ? SLURRED SPEECH   ? BPH (BENIGN PROSTATIC HYPERPLASIA)        5/3/2022 - DOV    No results found for this basename:  PSA:*    No results found for this basename:  PSAFREE:*     Pt symptoms are not bothersome enough to start treatment at this time, some aspect of blood sugar control may be involved as well.  care instructions provided.  F/u PSA ordered.      ? SLEEP APNEA       6/1/2021: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.    Sleep apnea evaluation and on CPAP.     Feels that things are doing well.    Feels that his CPAP is working, hasn't followed up with machine in a while.    ? HYPERLIPIDEMIA       5/3/2022: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.    On moderate intensity statin, lower dose.   Panel done at medical facility  8/8/2019 on Tricor and atorvastin  Component Name Value Ref Range Cholesterol 122 120 - 260 mg/dL Triglycerides 148 40 - 250 mg/dL HDL 41 28 - 68 mg/dL LDL/HDL Ratio 3.0  2 - 5  LDL Cholesterol 51 (L)         Lab Results Component Value Date   Cholesterol 119 09/09/2021   HDL 37 (L) 09/09/2021   LDL CALCULATED, NONFASTING 52 09/09/2021   TRIGLYCERIDE, NONFASTING 151 09/09/2021   triglycerides <500 remain on statin only, continue off of Tricor. Continue statin (atorvastatin 10)   ? HTN (HYPERTENSION)       5/3/2022: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.       BP Readings from Last 3 Encounters: 05/03/22 161/80 04/20/22 131/66 06/01/21 126/66   On Losartan-hctz and amlodipine.   Often the case that blood pressure is higher here in clinic than at home.  Will send updated bp from home.          ? DM 2       5/3/2022: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.       Lab Results Component Value Date   Hgb A1c % 7.9 (H) 04/14/2022   Hgb A1c % 8.2 (H) 12/09/2021   Hgb A1c % 7.6 (H) 09/09/2021    Is getting more lows at home.  Sometimes the insulin seems to work too well.  - will follow up with nurse for detailed strategy for his fluctuating blood sugars.     ? SEASONAL ALLERGIC RHINITIS       6/4/2020   Pt reported on his history questionnaire: 1st time ever had hayfever   care instructions provided    Wakes up with gunk around the eyes and occasionally takes a benadryl but that is as much as he does usually and occasion.  Does have claritin at home.   Encouraged claritin use instead of benadryl.      Resolved Hospital Problems No resolved problems to display.     Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code   Smoker: No.     Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).         DO   9/26/2023 11:47 AM  HBS              Note Details  Author (D.O.) File Time 9/26/2023  4:06 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/24/2023  ED to Hosp-Admission (Discharged) on 9/24/2023  ED to Hosp-Admission (Discharged) on 9/24/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   DM 2  HTN (HYPERTENSION)  HYPERLIPIDEMIA  TRANSIENT CEREBRAL ISCHEMIA  SEASONAL ALLERGIC RHINITIS  SLEEP APNEA  BPH (BENIGN PROSTATIC HYPERPLASIA)  ATAXIA  SLURRED SPEECH Care Timeline  09/24   Admitted from ED (Observation) 1819 09/26   Discharged 1403  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 9/26/2023)   Discharge Orders  30 DAY EVENT MONITOR, CV Medication List at Discharge   amlodipine besylate 10 mg Oral DAILY  aspirin 81 mg Oral DAILY  atorvastatin calcium 10 mg Oral DAILY  blood sugar diagnostic Use 4 times a day as directed to measure blood sugar. Measure blood sugar before meals and at bedtime  blood-glucose meter Use as directed  clopidogrel bisulfate 75 mg Oral DAILY  insulin NPH human isophane 100 unit/mL Inject 18 units subcutaneously each night or as directed to control blood glucose  insulin regular, human 100 unit/mL Inject subcutaneously as directed before each meal according to carbohydrate intake. CALL PROVIDER IF USING MORE THAN 60 UNITS PER DAY.  liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) Inject 1.2 mg under the skin daily . (Start AFTER finishing initial supply prescription)  loratadine 10 mg Oral DAILY AS NEEDED  losartan/hydrochlorothiazide 100-12.5 mg 1 tablet Oral DAILY  metformin HCl 1,000 mg Oral 2 TIMES A DAY  pen needle, diabetic 32 gauge x 5/32" Use for injection as directed  syringe-needle,insulin,0.5 mL 1/2 mL 31 gauge x 15/64" Use for injection as directed  tadalafil 20 mg Take 1 tablet by mouth as needed (30 minutes before sexual activity). Do not exceed 1 dose (1 tablet) in 24 hours