Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Red blood cells urine negative, Red cell distribution width normal, Respiratory syncytial virus test negative, SARS-CoV-2 test negative, Scan with contrast
Clinical narrative: Basic Information  Time Seen: 06/27/2022 13:11  Chief Complaint   Left sided weakness.  History Of Present Illness:     The patient is a 79 year old male who presents to ER with left sided weakness. Pt was at the pharmacy in town getting medicine for his wife. When he went to leave the pharmacy at 1130a, he kept running into the door. Pt states he was having a hard time controlling the left leg. Pt did have a very minor headache today that did not last very long. Otherwise denies other complaints. Denies fever, vision changes, chest pain, cough, SOB, sore throat, abdominal pain, N/V, bowel changes, urinary problems. Pt is on a low dose aspirin but otherwise no blood thinners. Family states he might have very early onset dementia. Denies history of bleeding problems or recent stroke or MI. Denies history of trauma.  Review of Systems:     Constitutional: No fevers, chills, fatigue  Eye: No recent visual problems  ENT: No ear pain, nasal congestion, sore throat  Respiratory: No shortness of breath, cough, no wheezing  Cardiovascular: No Chest pain, palpitations, tachycardia, diaphoresis, syncope,  Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, constipation  Genitourinary: No hematuria, no dysuria, no frequency  Hema/Lymph: No swollen lymph glands  Endocrine: Negative unexplained weight loss  Musculoskeletal: No back pain, neck pain  Integumentary: No rash  Neurologic: Alert & oriented, positive mild headache, no dizziness, no numbness or tingling  Psychiatric: No anxiety, depression  All systems otherwise negative/review of systems reviewed as documented in chart  Physical Exam  Vitals & Measurements  T: 36.8  °C (Oral)  HR: 62(Monitored)  HR: 60(Peripheral)  RR: 13  BP: 154/86  SpO2: 97%  HT: 178.000 cm  WT: 88.000 kg  BMI: 27.770  Stroke Scale Score: 1  O2 Therapy: Room air      General: Alert and oriented, well nourished, no acute distress.  Eye: PERRL, EOMI, normal conjunctiva. gross visual acuity and peripheral vision intact.  HENT: Normocephalic, normal hearing, moist oral mucosa.  Neck: Supple, non-tender, no lymphadenopathy.  Lungs: Clear to auscultation all lung fields, non-labored respiration. No wheezing.  Heart: Normal rate, regular rhythm, no murmur, no edema.  Skin: Skin is warm, dry and pink, no rashes or lesions.  Neurologic: Awake, alert and oriented to person, place. Pt believes it is June 17th, 2022. CN II-XII intact. SS 1 with ataxia to left LE. possible subtle weakness in left LE.  Psychiatric: Cooperative, appropriate mood and affect.  Medical Decision Making:     ddx: CVA, ACS, AMS        Reexamination/Reevaluation     1342: SS 0. neurology consulted about tPA administration. will discuss with family and pt about tPA  1404: medical center consulted about elevated troponin, go ahead with tPA and CTA head/neck  1524: medical center consulted about change in mental status and CTA results, CT head and nicardipine ordered, tPA paused. Transfer vehicle paged. Repeat stroke scale 12  1530: fentanyl ordered for headache  1551: back from CT head and patient is able to move his extremities and is conversing normally.  Stroke score 1  Assessment/Plan       1. CVA (cerebrovascular accident) The patient is a 79-year-old male presents to the ER for left-sided lower extremity weakness.  Vital signs stable.  Patient is not ill or toxic appearing, afebrile.  Initial stroke score is 1 with ataxia to the left lower extremity, could possibly be some subtle weakness.  Chest x-ray shows no acute findings, over read pending.  EKG shows normal sinus rhythm without ST elevation.  Initial troponin came back elevated at 326.5.  Patient does not exhibit any symptoms of an acute STEMI.  Medical center neuro was consulted about patient being a tPA candidate.  They agreed.  Patient and his family were involved in decision-making and agreed to go ahead with tPA administration.  They understood the benefits and risks associated with such.  CTA head ordered and came back showing a complete occlusion of right ICA.  Within 5 to 10 minutes after returning from CTA patient's mental status changed and he now is reading a stroke score of 12.  He is having difficulty following commands with left-sided extremity weakness and some aphasia.  CT head stat ordered.  Blood pressure became elevated, prior to nicardipine administration blood pressure returned to acceptable, will hold nicardipine on standby if needed.  tPA was paused until results of CT came back ruling out hemorrhage, then tPA resumed.  Patient was accepted for transfer to medical center by medical doctor; will transfer via transport vehicle. Services utilized for pt care. Doctor notified of pt's case and agreed with treatment and transfer. 2. NSTEMI (non-ST elevated myocardial infarction) Orders:   fentaNYL, 50 mcg = 1 mL, Soln, IV Push, Once, Routine, Start date 06/27/22 15:31:00, Physician Stop, Stop date 06/27/22 15:31:00, 06/27/22 15:31:00  Isovue-370, 100, mL, Injection, IV Push, Once, Routine, Start date 06/27/22 14:09:00, Physician Stop, Stop date 06/27/22 14:09:00, 06/27/22 14:09:00  niCARdipine additive 25 mg + Sodium Chloride 0.9% 250 mL, 250, mL, IV, Routine, Start date 06/27/22 15:24:00, Titrate - see comments, Total volume (mL): 250, 88 kg, 2.09, m2, 06/27/22 15:24:00  CT Angio Head +Angio Neck w/ + w/o Cont, 06/27/22 13:56:00, Routine, 06/27/22 13:56:00, left weakness/ataxia, No, Transport Mode: Walk, , No, , No, Rad Type  CT Head or Brain w/o Cont, 06/27/22 15:26:00, Routine, 06/27/22 15:26:00, AMS, No, Transport Mode: Walk, , No, , No, Rad Type  XR Chest 1 View, 06/27/22 13:20:00, Stat, 06/27/22 13:20:00, weakness, No, Transport Mode: Walk, , No, , No, Rad Type  level 5  Patient Discharge Condition  critical but stable  Discharge Disposition  transfer to medical center    Follow Up  No qualifying data available