Age: 52.0
Sex: M
Vaccine: COVID19-2
Symptoms: Vitamin B12 decreased, Vitamin B12 deficiency, White blood cell count normal
Clinical narrative: Per Hospital Discharge Summary:  HOSPITALIST DISCHARGE SUMMARY   Date of Service: 11/29/2022   Admission Date: 11/28/2022 Discharge Date: 11/29/22   Admitting Physician: MD Discharging Hospitalist: MD   PCP: MD   DISCHARGE DIAGNOSIS  Principal Problem:   TIA (transient ischemic attack) Active Problems:   Stroke (HCC) (HCC)   Hypertriglyceridemia   B12 deficiency     Primary Discharge Diagnosis Left-sided paresthesias Episodic vision loss, transient x2 weeks History of recent COVID-vaccine booster Hypertriglyceridemia Possible TIA versus ocular migraine OSA on CPAP Morbid obesity History of depression and schizoaffective disorder B12 deficiency     Consultants:  Neurology   Imaging Studies / Procedures  CT angiogram head and carotid neck   Result Date: 11/28/2022 Narrative: EXAM: CT ANGIOGRAM HEAD AND NECK 11/28/2022 CLINICAL HISTORY:  Neuro deficit  acute  stroke suspected; Stroke/TIA  assess intracranial arteries; Stroke/TIA  assess extracranial arteries TECHNIQUE: Helical axial CT imaging was performed through the brain. Axial reconstructions with coronal sagittal reformations were constructed and reviewed. During the bolus administration of 100 mL of Isovue-370 helical axial imaging was performed through the neck and brain. 0 mL of contrast were discarded. Two millimeter axial reconstructions, 2-D and 3-D volume rendering, and curved multiplanar reformats were constructed and reviewed. 3-D volume MIP reformations with dual energy technique plaque subtraction, and 3-D volume MIP reformations were also reviewed. Dose reduction technique utilized; automatic/anatomic modulation of X-ray tube current (Auto mA). COMPARISON: None. FINDINGS: Precontrast Head CT: No acute brain parenchymal or extra-axial hemorrhage. No mass effect or midline shift. Brain parenchymal volume is normal. Ventricles and cisterns are commensurate in size with the cerebral sulci. No hydrocephalus. Mild scattered nonspecific foci of cerebral white matter hypoattenuation, most likely representing sequelae of chronic small vessel ischemic disease. Gray-white differentiation is preserved. Calvarium is intact without evidence of acute  fracture. Paranasal sinuses and mastoid air cells are clear. Orbits and globes are unremarkable. Incidental trichilemmal cysts in the scalp. CTA Head: Minimal atherosclerotic plaque is demonstrated within the bilateral carotid siphons without flow-limiting stenosis. Proximal aspects of the bilateral middle and anterior cerebral arteries are widely patent. Anterior communicating artery is not definitely seen. The intracranial aspects of the vertebral arteries, basilar artery, and proximal aspects of the bilateral posterior cerebral arteries are widely patent. Posterior communicating arteries are diminutive or absent. No evidence of large vessel occlusion, dissection, aneurysm, or vascular malformation in the head. CTA Neck: Left-sided aortic arch. Conventional three-vessel branching anatomy of the great vessels from the aortic arch. The bilateral subclavian arteries are widely patent. Right neck arteries: There is no significant right carotid artery stenosis. The right vertebral artery is patent. No evidence of large vessel occlusion, dissection, aneurysm, or vascular malformation. Left neck arteries: There is no significant left carotid artery stenosis. The left vertebral artery is patent. No evidence of large vessel occlusion, dissection, aneurysm, or vascular malformation.    Impression: IMPRESSION: 1.  No acute intracranial pathology by CT. 2.  Mild presumed sequelae of chronic small vessel ischemic disease. 3.  No evidence of flow-limiting stenosis or occlusion involving the major arterial vasculature of the head or neck. Angiography, Computed Tomography Angiography, and Magnetic Resonance Angiography-    MR brain with and without contrast   Result Date: 11/28/2022 Narrative: Exam: MRI of the brain with and without contrast on 11/28/2022 Clinical history:  Neuro deficit  acute  stroke suspected Comparison(s): Head CT and CTA from 11/20/2022 Technique: Sagittal and axial T1, axial T2, axial FLAIR, axial diffusion weighted, axial gradient echo and post contrast T1-weighted images obtained. 28 cc of Prohance administered. 2 cc of contrast was discarded. Findings: There are no areas of abnormal signal intensity. No diffusion restriction or hemosiderin staining. There are no masses and there is no hydrocephalus. The CSF-containing spaces are normal in size, shape, and position. The midline structures are intact and the major central vascular structures are patent. Following contrast administration there are no areas of abnormal enhancement. The superficial and deep venous structures enhance normally. The visualized sinuses and mastoids are clear.    Impression: IMPRESSION: Normal pre-and postcontrast MRI of the brain.   XR chest portable 1 view   Result Date: 11/28/2022 Narrative: Exam: Portable chest, single view on 11/28/2022 at Clinical History: Shortness of breath Comparison(s): Chest x-ray 12/25/2014 Findings: The lungs are clear. The heart size and pulmonary vascularity are within normal limits.    Impression: IMPRESSION: No acute disease. Echo complete w saline   Result Date: 11/28/2022 Narrative: o Biplane ejection fraction is 72%. o Normal left ventricular systolic function. o Normal left ventricular cavity size. o Normal left ventricular diastolic function. o The left atrium is normal in size. o The right atrium is normal in size. o There is no patent foramen ovale detected by agitated saline but bubble study is of marginal technical quality o No pericardial effusion. o Inadequate TR spectral Doppler to accurately assess right ventricular systolic pressure. o Borderline concentric LVH       Pertinent Laboratory Studies     Results from last 4 days Lab Units 11/29/22 0803 11/28/22 1028 11/25/22 1440 WBC AUTO 10*3/uL 7.3 5.8 6.0 HEMOGLOBIN g/dL 15.0 13.4 14.5 HEMATOCRIT % 44.0 39.9 42.7 PLATELETS AUTO 10*3/uL 165 158 167   Results from last 4 days Lab Units 11/29/22 0803 11/28/22 1028 SODIUM mmol/L 138 138 POTASSIUM MMOL/L 3.9 4.0 CHLORIDE mmol/L 104 104 CO2 mmol/L 22 26 BUN mg/dL 13 14 CREATININE mg/dL 1.00 1.03 CALCIUM mg/dL 9.1 8.8 MAGNESIUM mg/dL  --  1.8 ALBUMIN g/dL 4.0 3.7 TOTAL PROTEIN g/dL 6.8 6.3 BILIRUBIN TOTAL mg/dL 0.60 0.41 ALK PHOS U/L 67 57 ALT U/L 11 10 AST U/L 14 13 GLUCOSE mg/dL 125* 84     Lab Results Component Value Date   CALCIUM 9.1 11/29/2022     Results from last 4 days Lab Units 11/28/22 1028 APTT SECONDS 28.0 INR   1.0     Results from last 4 days Lab Units 11/29/22 0803 TSH uIU/ml 2.254     Lab Results Component Value Date   VITAMINB12 171 (L) 11/29/2022           Lab Results Component Value Date   CHOL 157 11/29/2022   Lab Results Component Value Date   HDL 36 (L) 11/29/2022   Lab Results Component Value Date   LDLCALC 83 11/29/2022   Lab Results Component Value Date   TRIG 191 (H) 11/29/2022     Results from last 4 days Lab Units 11/28/22 1028 HEMOGLOBIN A1C % 5.4        Results from last 4 days Lab Units 11/25/22 1440 SED RATE mm/hr 6   Exam Temp:  [36.1 °C (96.9 °F)-36.6 °C (97.9 °F)] 36.1 °C (96.9 °F) Heart Rate:  [66-86] 86 Resp:  [14-19] 16 SpO2:  [93 %-97 %] 97 % BP: (113-155)/(71-97) 155/97   Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: Normal appearance. He is obese.  HENT:     Head: Normocephalic and atraumatic.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.      Hospital Course: 52 y.o. male with a PMH significant for depressions ans schizoaffective disorder, OSA (on CPAP) OA of his spine who presents to the hospital today by EMS from work where he was experiencing left-sided facial droop, bilateral facial numbness and left upper and lower extremity numbness and paresthesias, and visual changes.  Patient states his visual changes per the first symptom to start approximately 2 weeks ago following his most recent COVID booster.  He describes "blackouts "where suddenly he would not be able to see anything but a black screen and this would last for a few seconds and at the most a few minutes, before his vision would come back.  Patient states that he has never had symptoms like this prior to 2 weeks ago, and also to further complicate the history he has had some left-sided paresthesias and chronic headaches on and off for the last several years.     Patient was previously here on 11/25 for his visual changes and left-sided paresthesias, and at that time was seen by neurology in the emergency room.  He had a normal neurological exam, and the differential diagnosis was chronic headache with transient paresthesias versus ocular migraines but could not exclude a TIA with borderline hypertension and therefore he was supposed to have an outpatient MRI which was scheduled for today.  Patient states over the weekend, his paresthesias have continued, his transient visual changes have continued, but his new symptoms this morning at work were the left sided facial droop (according to his wife and boss)and his bilateral facial numbness.  He called his primary care provider, and she instructed him to come into the emergency room to be evaluated.  Neurology was contacted from the ER and they recommended admit to the hospital and an MRI with and without contrast.  Patient was noted to be hemodynamically stable upon admission, with a blood pressure of 157/102 which did drop to the 120s/70s, heart rate 81, 98% on room air with a respiratory rate of 16. Labs included a CBC, CMP, lipase, magnesium, troponin, INR and PTT as well as a urinalysis that were all within normal limits.   Patient denies a history of hypertension up until the last couple of weeks, denies hyperlipidemia, history of heart disease, any nausea or vomiting, diarrhea, urinary frequency or urgency.  He is not currently on any medication for his depression or schizoaffective disorder, but does participate in counseling.  Patient states he has had migraines or at least severe headaches on and off again for years, usually describes them as being over his left eye and causing some drainage from his left eye or over the top of his head bilaterally.  He does have a CPAP at home, but only wears it intermittently stating that it needs to be "recalibrated ".  He denies a history of any alcohol use, denies using any illicit substances including methamphetamine or marijuana, and does not smoke.   He rec'd his COVID booster 2 weeks ago and said this is when his symptoms started.    Patient was admitted to the hospital, subsequently placed on neurochecks, had a bedside neuro eval that he passed, and received a loading dose of Plavix 300 mg as well as a 81 mg aspirin.  He was started on atorvastatin 80 mg nightly, and an MRI of the brain was obtained.  Due to some concern of an underlying diagnosis of multiple sclerosis or something like that this was obtained with and without contrast.  This was read as normal.  He also had a echocardiogram and this showed an EF of 72%, normal LV systolic function cavity size and normal LA and RA size.  No PFO was identified and he has some borderline concentric LVH.   We did get a lipid panel that was fasting, and this indicated high triglycerides of 191, total cholesterol 157 and HDL 36 with an LDL of 83.  I did initiate him on Lipitor 40 mg nightly at discharge.  He should also abide by a triglyceride healthy diet follow-up with his PCP.  Other than that as his B12 was low, and I recommended replacement.  Other labs including an A1c, TSH, lipase, were all normal.   We are discharging him on a 14-day event monitor, neurology recommended Plavix for 21 days which has been prescribed, and aspirin 81 mg going forward.  Patient does take ibuprofen nightly, 1200 mg.  I did warn him about the combination of Plavix aspirin and ibuprofen and cautioned him to separate these as well as taking them with food and decreasing his dosing of ibuprofen until he is done with the Plavix.  In the event that he would have black stools or any signs of bleeding, he should return to the emergency room.    We discussed with his symptoms could be due to, and it is possible that his COVID booster given in his left arm caused his left arm paresthesias.  It is also possible that this has caused his transient vision loss although we have no proof of this.  With a normal MRI of the brain, I have recommended he follow-up with his optometrist regarding his visual symptoms. The below instructions were gone over with both he and his wife at the bedside on the day of discharge.  He had a normal neurological exam as he did when he first came in.  He denies any visual symptoms this morning.  He will need to follow-up with his primary care provider.  Prescriptions were sent to store as per requested by the patient.     1. Full Code  2. Condition on Discharge.  Stable  3.     Discharge medication list     START taking these medications      Instructions aspirin 81 mg chewable tablet Start taking on: November 30, 2022   Take 1 tablet (81 mg total) by mouth daily   atorvastatin 40 mg tablet Commonly known as: LIPITOR   Take 1 tablet (40 mg total) by mouth daily   clopidogreL 75 mg tablet Commonly known as: PLAVIX Start taking on: November 30, 2022   Take 1 tablet (75 mg total) by mouth daily for 20 doses         CONTINUE taking these medications      Instructions acetaminophen 650 mg 8 hr tablet Commonly known as: TYLENOL     ibuprofen 200 mg tablet Commonly known as: ADVIL,MOTRIN             Where to Get Your Medications     These medications were sent to Pharmacy      Phone:  ? aspirin 81 mg chewable tablet ? atorvastatin 40 mg tablet ? clopidogreL 75 mg tablet       Discharge Instructions and Follow-up 01 - Home or Self-Care 1. Diet will be regular.  2. Activity will be as tolerated.   3. Follow up: Call to schedule an appointment with MD in the next 7-10 days 4. Patient was given the following instructions at the time of discharge:   You are being discharged from the hospital. Your MRI was normal, with no indication of any large stroke or any other disease processes. That being said, it is still possible you could have had a TIA (a mini stroke). It is possible you are having ocular migraines. You should follow up with your eye doctor as well. Per neurology recommendations, you will complete a 21 day course of plavix which is an anti-platelet medication. I have prescribed this. Please take it in the morning. Also we recommend you take a 'baby aspirin', the 81mg tablet, daily going forward. This can be purchased over the counter. These two medications along with the ibuprofen you already take could increase your risk of bleeding. If you notice black stools, please come to the ER immediately. You should take all these medications with food.  As we have discussed your triglycerides are high. I will prescribe a cholesterol medication. Your PCP may want to check your liver enzymes in a couple of weeks and also recheck your cholesterol panel in a couple of months.  We did check a B12 level, which was low, so I recommend replacement. You can buy this over the counter. After several months, this blood level can be rechecked to make sure the vitamin is working well for you.  Your arm paresthesias could have been from your vaccine booster you received but we can't be sure about this.  Also, you will wear a heart monitor for two weeks. Someone will call you with these results after it is analyzed.      Time spent coordinating discharge: 40 min, of which > 25 mins on was spent on coordinating care & Counseling.