Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin normal, Hypertensive emergency, Hypoaesthesia, International normalised ratio normal, Laboratory test
Clinical narrative: \Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on March 16, 2022 20:45   Verified By: MD on March 21, 2022 19:13   Encounter Info: Hospital, Observation, 03/16/22 - 03/18/22    * Final Report *        Basic Information  Time Seen:  03/16/2022 20:33  Chief Complaint  Numbness/tingling (Complaint of), Weakness (Complaint of)  History of Present Illness     The pt is a 69 y/o male who presents to the ED via PV c/o stroke-like symptoms onset 10:30 PM yesterday. The pt reports that he noticed his stroke like symptoms this morning after he awoke. The pt endorses the following: L arm paresthesia, L arm weakness, and poor balance. The pt states that he has a relevant PMHx of blood clots in his arms, but is not on any blood thinners at the moment.  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in 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:  No headache,  + L-arm weakness,  no numbness+L-arm Paresthesia, +poor balance Psychiatric:  No anxiety,  no depression  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.7 DegC  Heart Rate:       67 bpm  Resp Rate:       18 br/min  BP #1:       226 / 111 mmHg  SpO2 (%):       98 %  O2 Device:       Room air     Height CM: 175.3 cm  Weight KG: 76.4 kg  Ideal Body Weight: 70.74 kg     NIH Stroke Scale  Level of consciousness alert = 0 Current month and age answers both correctly = 0 Opens and closes eyes/grip release hand obeys both correctly = 0 Best gaze normal = 0 Visual field testing no visual field loss = 0 Facial paresis normal symmetric movement = 0 Motor function of L arm normal = 0 Motor function of R arm normal = 0 Motor function of L leg normal = 0 Motor function of R leg normal = 0 Limb ataxia no ataxia = 0 Sensory normal = 0 Best language no aphasia = 0 Dysarthria normal aticulation = 0 Extinction and inattention normal = 0  Total Score: 4       Medical Decision Making     Documents Reviewed:  ED nurse, prior records  Diagnostic Results:  Labs: Reviewed Imaging: Reviewed            Condition     Stable  Scribe Attestation  I, acting as scribe for Dr. at 03/16/22 20:45:03 Signed by Scribe, at 03/16/22 20:45:03   I, MD, attest that the scribes documentation has been prepared under my direction in person and by me in its entirety.  I confirm that the note above accurately reflects the work, treatment, procedures, and medical decision-making performed by me. chart edited and reviewed     Assessment/Plan       GERD (gastroesophageal reflux disease)       Hypertensive emergency       Prostate cancer       Pulmonary emboli       Sleep apnea       TIA (transient ischemic attack)        Patient Education   High Blood Pressure (Hypertension), Discharge Instructions  TIA: Transient Ischemic Attack  Follow Up        With  When  Contact Information        MD, 03/22/2022 09:45 AM Hospital  Additional Instructions: Appointment is with Dr.        Chronic Problem List    Actinic keratoses  Back pain  Blood pressure elevated without history of HTN  Encounter for long-term (current) use of medications  GERD (gastroesophageal reflux disease)  Lipid screening  Myalgia and myositis  Obesity  Prostate cancer  Pulmonary emboli  Sleep apnea  Procedure/Surgical History  ?basal cell carcinoma removal of right shoulder ?prostate ca 2013 ?shaved disc lumbar approx age 2007  Medications  No qualifying data available    Allergies   Zofran (Unknown)  sulfa drugs (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   married   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Car accident: Mother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  03/16/22 20:36  8.8  12/23/20  7.9          RBC  03/16/22 20:36  5.35  12/23/20  5.39          Hgb  03/16/22 20:36  15.2  12/23/20  15.7          Hct  03/16/22 20:36  43.0  12/23/20  44.7          MCV  03/16/22 20:36  80  Low  12/23/20  83          MCH  03/16/22 20:36  28.3  12/23/20  29.1          MCHC  03/16/22 20:36  35.3  12/23/20  35.1          RDW  03/16/22 20:36  14.4  12/23/20  13.8          Platelet  03/16/22 20:36  186  12/23/20  155          MPV  03/16/22 20:36  9.4  12/23/20  9.5          Neutrophils %  03/16/22 20:36  64  12/23/20  72          Lymphocytes %  03/16/22 20:36  24  12/23/20  18          Monocytes %  03/16/22 20:36  8  12/23/20  8          Eosinophils %  03/16/22 20:36  3  12/23/20  2          Basophils %  03/16/22 20:36  0  12/23/20  1          Absolute Neutrophil  03/16/22 20:36  5.6  12/23/20  5.7          Absolute Lymphocyte  03/16/22 20:36  2.1  12/23/20  1.4          Absolute Monocyte  03/16/22 20:36  0.7  12/23/20  0.6          Absolute Eosinophil  03/16/22 20:36  0.3  12/23/20  0.2          Absolute Basophil  03/16/22 20:36  0.0  12/23/20  0.0          Routine Coagulation Studies FS  LATEST RESULTS        PT  03/16/22 20:36  12.2        INR  03/16/22 20:36  1.03           Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  03/16/22 20:36  140  12/23/20  140          Potassium SerPl QN  03/16/22 20:36  3.5  12/23/20  4.2          Chloride SerPl QN  03/16/22 20:36  103  12/23/20  104          Carbon Dioxide SerPl QN  03/16/22 20:36  29  12/23/20  31  High          Anion Gap  03/16/22 20:36  8  12/23/20  5          BUN SerPl QN  03/16/22 20:36  14  12/23/20  12          Creatinine SerPl QN  03/16/22 20:36  1.21  12/23/20  1.25          Estimated GFR (CKD-EPI)  03/16/22 20:36  61  12/23/20  59  Low          Estimated CRCL (CG)  03/16/22 20:36  60  12/23/20  59          Glucose SerPl QN  03/16/22 20:36  91  12/23/20  94          Calcium Total SerPl QN  03/16/22 20:36  9.0  12/23/20  9.0          Troponin-I High Sensitivity  03/16/22 20:36  5              BNP Pl QN  03/16/22 20:36  38          Diagnostic Results  CT Head W/o IV Contrast    03/16/22 22:00:17  IMPRESSION:  1. Chronic findings as above without acute intracranial abnormality.  If continued clinical concern for stroke, MRI may be of value.       Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further can  contact the Emergency Radiology Room.   Electronically Signed by:     Signed By: MD     ************************************************** XR Chest PA or AP Portable    03/16/22 21:59:11  IMPRESSION:  1. No acute findings in the chest.   Thank you for consulting our team of subspecialty radiologists.  Healthcare providers wishing to discuss this case further can  contact the Emergency Radiology Room.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 03/17/22 00:23  ________________________________________________________  Electronically Signed on 03/21/22 19:13  ________________________________________________________ MD