Age: 74.0
Sex: M
Vaccine: FLU3
Symptoms: Computerised tomogram head normal, Computerised tomogram neck abnormal, Creatinine renal clearance decreased, Dizziness postural, Dysarthria
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: DO on November 11, 2024 02:30    Verified By: DO on November 11, 2024 06:07   Encounter Info: Hospital, Emergency, 11/11/24 - 11/11/24    * Final Report *        Basic Information  Time Seen: DO / 11/11/2024 02:21  Chief Complaint  Altered mental status (Complaint of), Headache (Complaint of)  History of Present Illness     Patient presents emergency department by private vehicle with his wife with concern for possible stroke.  His wife provides the history.  She states that they went to sleep around 10:00 last night and normal state of health.  She woke around 1:40 in the morning and noticed the patient was awake and slightly slumped to the right.  She asked him if he was okay and if he needed to use the restroom and she reports his speech was slurred and did not make sense.  She noticed that his right arm seemed weak compared to the left.  She states that the symptoms lasted about 10 minutes and then seemed to resolve on their own.  Patient has no complaints at time of exam.  He does state that for the last 2 or 3 weeks he has had issues with lightheadedness when standing up.  He also complains of a headache today and states that he has been having issues with some headaches over the past 2 weeks as well.  Review of Systems      Constitutional:  no fever, no chills, no sweats, no weakness Respiratory:  no shortness of breath, no cough Cardiovascular:  no chest pain Additional ROS info:  Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements most recent  T: 36.4 °C (Oral)  BP: 147/85  HR: 57 (Monitored)  RR: 18  SpO2: 98%  Oxygen Therapy: Room air  WT: 179.80 kg (WFC)  HT: 180.3 cm       General:  alert, no acute distress Skin:  warm, dry Head:  no trauma, normocephalic Neck:  trachea midline, no adenopathy, no tenderness Eye:  normal conjunctiva, clearsclera Cardiovascular:  regularrate and rhythm, normalperipheral perfusion Respiratory:  Lungs CTA, respirations non-labored Chest wall:  no deformity Gastrointestinal:  soft, non-distended, no tenderness _, no guarding _ Extremities:  no deformity, no trauma Neurological:  oriented x4  , LOC appropriate for age, CNII-XII intact, motor strength equal and normal bilaterally, sensation equal and normal bilaterally  , speech normal Psychiatric:  Cooperative ,  appropriate for ageaffect  , normal  judgement,  normal psychiatric thoughts  Medical Decision Making     DDx: TIA, CVA seems unlikely as symptoms have resolved, consider orthostatic hypotension, vertigo  History provided by: Patient, spouse Prior records reviewed: None Social Determinants of Health: None Interpretations (EKG, Imaging): All labs, imaging, and EKG independently interpreted by myself, DO  Rate: 58  Rhythm: Sinus bradycardia  Axis: LAD  Conduction: Complete RBBB  ST segments: No acute change  T waves: TWI in III  Q waves: None  Impression: SB, LAD, complete RBBB, TWI in III  Comparison to old: 11/8/24 - No change  Treatments: None Advanced Monitoring required: Yes Admission considered: Upon initial evaluation, admission is considered depending upon results of work-up Misc discussion: Discussed workup with patient and spouse which at this point is largely reassuring.  Blood work is stable, CT head shows no intracranial hemorrhage, CTA does show some cervical artery stenosis but no large vessel occlusion.  Patient continues to complain of some headache and dizziness and discussed obtaining an MRI and patient and wife are agreeable with this plan. Consultations: None Disposition: Pending Prescriptions: Pending    I have transitioned care of the patient to Dr, we have discussed the clinical presentation, work-up, and ED course thus far.              Condition     Stable  Assessment/Plan      1. Headache   R51.9    2. Dizziness   R42    3. Stroke-like symptoms   R29.90    Orders:   aPTT Pl QN  Auto Diff  Basic Metabolic Panel  Cardiac Monitor  CBC w/Differential  CT Head W/O IV Contrast  CTA Head/Neck W/IV Contrast  Electrocardiogram  MRI Brain W/O IV Contrast  Peripheral IV Insertion  PTINR  Troponin-I High Sensitivity  Troponin-I High Sensitivity     Follow Up  No qualifying data available   Chronic Problem List    Allergic rhinitis  Aortic ectasia  B12 deficiency  Basal cell carcinoma of face  CAD (coronary artery disease), native coronary artery  Chronic insomnia  Decreased hearing of left ear  Dysfunction of left eustachian tube  Erectile dysfunction  GERD (gastroesophageal reflux disease)  Hyperlipidemia, mixed  Hyperplasia, prostate  Hypertension  Intolerance of continuous positive airway pressure (CPAP) ventilation  Kidney stones  Long term use of drug  Medicare annual wellness visit, subsequent  Microscopic hematuria  Mild aortic regurgitation  Myringotomy tube status  OSA (obstructive sleep apnea)  Pain in joint involving multiple sites  Primary osteoarthritis of right knee (Mod/Severe MC)  Seborrheic keratoses  Second degree type I atrioventricular block  Thyromegaly  Tobacco use  Tubular adenoma of colon  Type B tympanogram  Unspecified Eustachian tube disorder, left ear  Procedure/Surgical History  ?Cardiac catheter (06/12/2024) ?L ear tube (2024) ?cardiac Cath with one stent (05/19/2021) ?Eye examination (04/23/2019) ?Colonoscopy (05/15/2018) ?Lesion excisoin (11/24/2015) ?Heart Attack with Stent (2014) ?Colonoscopy (09/17/2007) ?rt knee replacement ?Tonsillectomy and adenoidectomy  Surgical History Internal  05/15/2018    Colonoscopy Bx    MD  Medications  Home Medications (13) Active amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily Bayer Aspirin Regimen 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, Daily losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily multivitamin , QPM Neuriva Ultra Brain Health , Orally, QAM nicotine 14 mg/24 hr transdermal film, extended release 1 Patch, Topical, Daily nicotine 21 mg/24 hr transdermal film, extended release 1 Patch, Topical, Daily nicotine 7 mg/24 hr transdermal film, extended release 1 Patch, Topical, Daily nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily pravastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, At Bedtime Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, QAM Vitamin D3 (cholecalciferol) 50 mCg, Orally, QAM    Allergies   Lipitor (diarrhea)  lisinopril (cough)  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Married 3 Children, Lives with Spouse.   Nutrition/Health   Caffeine intake amount: 3-4 servings/day.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days. 1 packs per day. Started age 15.0 Years. Ready to change: No. Smoking cessation information given: Yes.  Family History   Cancer: Mother.  Congestive heart failure..: Mother.  Diabetes mellitus type 2: Mother.  Stroke: Mother.   Deceased Family Member(s)  Relationship: Mother, Age: Unknown  Relationship: Father, Age: Unknown, Cause: AAA  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  11/11/24 02:52  7.1  11/08/24  5.3          RBC  11/11/24 02:52  4.44  11/08/24  4.62          Hgb  11/11/24 02:52  13.9  11/08/24  14.6          Hct  11/11/24 02:52  41.0  11/08/24  42.9          MCV  11/11/24 02:52  92  11/08/24  93          MCH  11/11/24 02:52  31.3  11/08/24  31.7          MCHC  11/11/24 02:52  33.9  11/08/24  34.1          RDW  11/11/24 02:52  13.8  11/08/24  13.4          Platelet  11/11/24 02:52  346  11/08/24  337          MPV  11/11/24 02:52  8.9  11/08/24  8.4          Neutrophils %  11/11/24 02:52  57  11/08/24  57          Lymphocytes %  11/11/24 02:52  33  11/08/24  31          Monocytes %  11/11/24 02:52  7  11/08/24  10          Eosinophils %  11/11/24 02:52  2  11/08/24  2          Basophils %  11/11/24 02:52  0  11/08/24  0          Absolute Neutrophil  11/11/24 02:52  4.1  11/08/24  3.0          Absolute Lymphocyte  11/11/24 02:52  2.4  11/08/24  1.6          Absolute Monocyte  11/11/24 02:52  0.5  11/08/24  0.5          Absolute Eosinophil  11/11/24 02:52  0.2  11/08/24  0.1          Absolute Basophil  11/11/24 02:52  0.0  11/08/24  0.0           Routine Coagulation Studies FS  LATEST RESULTS  HISTORICAL RESULTS          PT  11/11/24 02:52  11.0  06/19/24  11.5          INR  11/11/24 02:52  0.94  06/19/24  0.98          aPTT  11/11/24 02:52  30.7  06/20/24  51.6  High           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  11/11/24 02:52  141  11/08/24  139          Potassium SerPl QN  11/11/24 02:52  4.0  11/08/24  4.4          Chloride SerPl QN  11/11/24 02:52  108  11/08/24  106          Carbon Dioxide SerPl QN  11/11/24 02:52  25  11/08/24  26          Anion Gap  11/11/24 02:52  8  11/08/24  7          BUN SerPl QN  11/11/24 02:52  21  High  11/08/24  18          Creatinine SerPl QN  11/11/24 02:52  1.20  11/08/24  1.14          Estimated GFR (CKD-EPI, no race)  11/11/24 02:52  63  11/08/24  67          Estimated CRCL (CG)  11/11/24 02:52  59  11/08/24  62          Glucose SerPl QN  11/11/24 02:52  88  11/08/24  81          Gluc-Strip, POC  11/11/24 02:27  93              Calcium Total SerPl QN  11/11/24 02:52  9.4  11/08/24  9.5          Troponin-I High Sensitivity  11/11/24 04:16  8  06/20/24  444  High      Diagnostic Results  CT Head W/o IV Contrast    11/11/24 05:10:56  IMPRESSION:  1. No acute CT abnormality of the head. No acute intracranial  hemorrhage or hydrocephalus.     Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.   Electronically Signed by     Signed By:  MD     ************************************************** CTA Head/Neck W/IV Contrast    11/11/24 05:15:50  IMPRESSION:  1. Suboptimal exam due to poor contrast bolus timing. The vertebral  arteries in particular are not well evaluated.  2. No large vessel occlusion.  3. Cervical arterial atherosclerosis most significantly causing this  65% narrowing of the distal right common carotid artery and 70%  narrowing of the proximal right internal carotid artery.  4. Stable right apical pulmonary mass.     Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.   Electronically Signed by     Signed By:  MD        Signature Line Electronically Signed on 11/11/24 06:07  ________________________________________________________ DO