Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Encounter Info: Hospital, Observation, 05/28/23 -     * Final Report *        Basic Information  Time Seen: 05/28/2023 01:00  Chief Complaint  Slurred Speech  History of Present Illness     Patient seen: 05/28/23 01:12:02 A 68 year old male with Hx of CHF, CAD, COPD, T2DM, HTN, MI, HLD, and CVA, presents to the ED via EMS c/o slurred speech. Patient presents after a fall at home. EMS reports that the patient was garbled and he was hypotensive en route. He states that his speech is slurred secondary to dry mouth. Patient has abrasions to bilateral elbows, but denies any pain. He endorses generalized weakness. Denies hitting head, shortness of breath, cough, nausea, vomiting, or diarrhea.  Review of Systems     Constitutional:  no fever, no chills, no sweats, +weakness Skin:  no jaundice, no rash, no lesions, no petechiae ENMT:  no ear pain, no sore throat, no congestion, no hoarseness Respiratory:  no shortness of breath, no cough, no orthopnea, no wheezing Cardiovascular: no chest pain, no palpitations, no edema Gastrointestinal:  no nausea, no vomiting, no diarrhea, no GI bleeding Genitourinary:  no dysuria, no hematuria, no discharge, no pain Musculoskeletal:  no back pain, no trauma Neurologic:  no headache, no dizziness, no numbness, no weakness, +slurred speech Psychiatric:  no sleeping problems, no irritability, no mood swings/depression Heme/Lymph:  no bleeding tendency, no bruising tendency, no petechiae, no swollen nodes Allergy/Immunologic:  no seasonal allergies, no food allergies, no recurrent infections, no impaired immunity 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: 36.5 °C (Oral)  BP: 102/64  HR: 116 (Monitored)  RR: 20  SpO2: 100%  Oxygen Therapy: Room air  WT: 49.70 kg (WFC)  HT: 162.6 cm      General:  alert, no acute distress Skin:  warm, dry Head:  no trauma, normocephalic, mouth and oropharynx very dry Neck:  trachea midline, no adenopathy, no tenderness Eye:  normal conjunctiva, clearsclera Cardiovascular:  tachycardicrate and regular 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, abrasions and skin tears to bilateral elbows Neurological:  oriented x4  , LOC appropriate for age, CNII-XII intact, bilaterally  , no facial droop, motor function and sensation intact in all four extremities. Speech somewhat thick but easily understood Psychiatric:  Cooperative ,  appropriate for ageaffect  , normal  judgement,  normal psychiatric thoughts  Medical Decision Making     DDx: ischemic stroke, hemorrhage stroke, dehydration, UTI  History provided by: Patient Prior records reviewed: Internal medicine note from 5/25/2023 Social Determinants of Health: Previous CVA, medically complicated Interpretations (EKG, Imaging): CBC, BMP, coags, CK, troponin, lactate, EtOH, UA, CT head, CTA head/neck, chest x-ray  Rate: 117 bpm Rhythm: Sinus tachycardia Axis: normal Conduction: normal ST segments: no changes T waves: no changes Q waves: inferior Q waves Impression: Sinus tachycardia with likely old ischemic changes Comparison to old: Compared with previous from 2/15/23 Rate is faster, but otherwise unchanged  Treatments: IV fluids, Zosyn, vancomycin Advanced Monitoring required: No Admission considered: No Misc discussion: Patient does have a significant leukocytosis but it appears chronic, going back to 2/23. It is higher than before but may be due to hemoconcentration as patient appears clinically very dehydrated. After wetting his mouth with a swab, his speech is essentially back to normal, no slurring, clear and fluent.  05/28/23 05:02:34 On repeat, patient's WBC has actually gone up to 28.6, unclear etiology. CXR is clear, UA shows no signs of UTI. Patient does have chronic gangrene of his right great toe, scheduled for TMA on 6/1/23. Will obtain an x-ray of his right foot to assess for osteomyelitis, as well as a CT abdomen/pelvis to assess for intraabdominal infection. Patient denies any issues or complaints currently, no pain, no nausea. Consultations: 05/28/23 02:38:19 Contacted by radiologist who states there is a large, old infarct in the left parietal lobe but no obvious acute infarct, no hemorrhage. CTA shows likely chronic left PCA occlusion but no large vessel occlusion. 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.       Procedures     Procedure: NIH Stroke Scale Date/Time: 05/28/23 01:40:42 Level of consciousness: Alert=0 Current month and age: Answers both correctly=0 Open and close 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 left arm: Normal=0 Motor function right arm: Normal=0 Motor function left leg: Normal=0 Motor function right leg: Normal=0 Limb ataxia: No ataxia=0 Sensory: Normal=0 Best language: No aphasia=0 Dysarthria: Mild to moderate slurring of words=1 Extinction and inattention: Normal=0 Total score: 1 (severe deficit >22)    Condition     Stable  Assessment/Plan       1. Dysarthria   2. History of CVA (cerebrovascular accident)   3. Leukocytosis    Orders:   aPTT Pl QN  Auto Diff  Auto Diff  Basic Metabolic Panel  Blood CX  Blood CX  Cardiac Monitor  CBC w/Differential  CBC w/Differential  CK SerPl QN  CT Abd/Pelvis W/IV Contrast  CT Head W/O IV Contrast  CTA Head/Neck Stroke W/IV Contrast  Electrocardiogram  Ethanol Pl QN  Lactate Pl Venous QN  Lactate Pl Venous QN  Peripheral IV Insertion  PTINR  Sepsis Tracking  Troponin-I High Sensitivity  Troponin-I High Sensitivity  UA Microscopic  Urinalysis w Culture Rflx  XR Chest PA or AP Portable  XR Foot 3 View Right     Follow Up  No qualifying data available   Chronic Problem List    Acute HFrEF (heart failure with reduced ejection fraction)  AICD (automatic cardioverter/defibrillator) present  Aortocoronary bypass status  Atherosclerosis of left lower extremity with rest pain  Atherosclerosis of right lower extremity with rest pain  Bilateral leg pain  Bilateral swelling of feet  CAD (coronary artery disease)  Chest pain in adult  Chronic respiratory failure  Chronic, continuous use of opioids  COPD (chronic obstructive pulmonary disease)  Diabetes mellitus with neuropathy  Diabetic neuropathy  Diabetic ulcer of heel with fat layer exposed  Dyskinesia of esophagus  ED (erectile dysfunction)  Enlarged prostate  Essential hypertension  Gangrene of toe  History of MI (myocardial infarction)  Hyperlipidemia  Ischemic cardiomyopathy  Muscular atrophy  Onychogryphosis  Onychomycosis  Painful diabetic neuropathy  PVD (peripheral vascular disease)  S/P implantation of automatic cardioverter/defibrillator (AICD)  SIRS (systemic inflammatory response syndrome)  Status post amputation of toe of right foot  Tobacco use  Uncontrolled type 2 diabetes mellitus with complication  Procedure/Surgical History  ?Lower extremity angiogram (10/15/2020) ?rt leg angiogram (10/01/2019) ?Lt femoral artery angiogram (09/20/2019) ?Diabetic retinal eye exam (06/05/2019) ?Ultrasound scan of carotid (11/21/2016) ?Aortocoronary artery bypass graft (04/2013) ?Aortocoronary artery bypass graft (2010)  Surgical History Internal  10/15/2020    AARO      02/27/2020    Toe Amputation  (Right)     11/15/2019    Toe Amputation  (Right)     10/01/2019    AARO  (Right)     09/20/2019    AARO      Medications  Home Medications (23) Active albuterol 90 mCg/inh inhalation powder 2 Puff, PRN, Inhalation, Q6H amitriptyline 50 mg oral tablet 50 mg = 1 Tablet, Orally, At Bedtime aspirin 325 mg oral tablet 325 mg = 1 Tablet, Orally, Daily atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, At Bedtime Blood Glucose Meter (ONCE) Not Applicable, Other, Unscheduled, check daily clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily DME (Vendor) Walker See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed. furosemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q8H Lancet Device (ONCE) Not Applicable, Other, Unscheduled, check daily Lancet Device (ONCE) Not Applicable, Other, Unscheduled, check up to 2 times daily Lancets See Instructions, check blood glucoses twice daily metFORMIN 500 mg oral tablet 1,000 mg = 2 Tablet, Orally, BID Misc Med 0.25 mL, MORPHINE  PRN Misc Supplies See Instructions, BP cuff nalOXone 4 mg / 0.1 mL nasal spray 1 Spray, PRN, Nostrils, Both nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min omeprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, QAM ondansetron 4 mg oral tablet, disintegrating 1-2 Tablet, PRN, Orally, Q6H Senna Plus 50 mg-8.6 mg oral tablet See Instructions, 2 TAB PO QAM,  3 TAB PO QHS sertraline 50 mg oral tablet 25 mg, Orally, Daily Strips - Glucose Test Check up to 2 times daily, Other, Unscheduled, Dispense QS 90 days Syringes - Insulin Use up to 2 times daily, Other, Unscheduled, Dispense QS 90 days  Medication Administration   Given  Sodium Chloride 0.9% - ED Bolus, 500 mL, IVPB  Sodium Chloride 0.9% - ED Bolus, 500 mL, IVPB  vancomycin, IVPB. For: Sepsis (Update Indication in 36-48 hrs)  Zosyn, IVPB. For: Sepsis (Update Indication in 36-48 hrs)  Allergies   codeine (Diarrhea, Vomiting, Nausea)  Pulmicort Turbuhaler (Made lungs hurt)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Nutrition/Health   Caffeine intake amount: 4 servings per day.   Substance Abuse   Denies   Tobacco   Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days.  Family History   Cancer of lung...: Brother.  Congestive heart failure..: Father.  Diabetes mellitus type 2: Mother.  Diabetes...: Sister.  Hypertension..: Sister.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  05/28/23 04:16  28.6  High  05/25/23  14.2  High          RBC  05/28/23 04:16  3.68  Low  05/25/23  4.23          Hgb  05/28/23 04:16  10.8  Low  05/25/23  12.5  Low          Hct  05/28/23 04:16  33.0  Low  05/25/23  37.6  Low          MCV  05/28/23 04:16  90  05/25/23  89          MCH  05/28/23 04:16  29.3  05/25/23  29.6          MCHC  05/28/23 04:16  32.6  05/25/23  33.3          RDW  05/28/23 04:16  16.6  High  05/25/23  17.3  High          Platelet  05/28/23 04:16  281  05/25/23  388          MPV  05/28/23 04:16  8.8  05/25/23  8.8          Neutrophils %  05/28/23 04:16  95  05/25/23  77          Lymphocytes %  05/28/23 04:16  1  05/25/23  15          Monocytes %  05/28/23 04:16  3  05/25/23  6          Eosinophils %  05/28/23 04:16  0  05/25/23  1          Basophils %  05/28/23 04:16  1  05/25/23  1          Absolute Neutrophil  05/28/23 04:16  26.2  High  05/25/23  10.9  High          Absolute Lymphocyte  05/28/23 04:16  0.3  Low  05/25/23  2.1          Absolute Monocyte  05/28/23 04:16  0.8  05/25/23  0.9          Absolute Eosinophil  05/28/23 04:16  0.0  05/25/23  0.1          Absolute Basophil  05/28/23 04:16  0.2  05/25/23  0.1           Routine Coagulation Studies FS  LATEST RESULTS  HISTORICAL RESULTS          PT  05/28/23 01:21  14.4  High  02/15/23  12.8          INR  05/28/23 01:21  1.25  02/15/23  1.12          aPTT  05/28/23 01:21  31.1  02/15/23  32.7           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  05/28/23 01:21  139  05/25/23  137          Potassium SerPl QN  05/28/23 01:21  3.6  05/25/23  4.7          Chloride SerPl QN  05/28/23 01:21  102  05/25/23  102          Carbon Dioxide SerPl QN  05/28/23 01:21  24  05/25/23  30  High          Anion Gap  05/28/23 01:21  13  High  05/25/23  5          BUN SerPl QN  05/28/23 01:21  32  High  05/25/23  17          Creatinine SerPl QN  05/28/23 01:21  0.65  Low  05/25/23  0.52  Low          Estimated GFR (CKD-EPI, no race)  05/28/23 01:21  >90  05/25/23  >90          Estimated CRCL (CG)  05/28/23 01:21  76  05/25/23  96          Glucose SerPl QN  05/28/23 01:21  155  High  05/25/23  102  High          Gluc-Strip, POC  05/28/23 01:00  165  High  02/10/23  459  High          Calcium Total SerPl QN  05/28/23 01:21  9.0  05/25/23  9.2          CK SerPl QN  05/28/23 01:21  230  High              Troponin-I High Sensitivity  05/28/23 01:42  20  02/15/23  8          Lactate Venous Pl QN  05/28/23 04:16  1.4  04/13/23  1.0          Toxicology  LATEST RESULTS        Ethanol Pl QN  05/28/23 01:21  <10           Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  05/28/23 04:09  Light-Yellow  02/15/23  Yellow          Clarity  05/28/23 04:09  Clear  02/15/23  Clear          Specific Gravity  05/28/23 04:09  >1.050  High  02/15/23  <=1.005          pH  05/28/23 04:09  5.5  02/15/23  7.0          Protein  05/28/23 04:09  10 Abnormal  02/15/23  30 Abnormal          Glucose  05/28/23 04:09  Normal  02/15/23  Negative          Ketones  05/28/23 04:09  20 Abnormal  02/15/23  40 Abnormal          Bilirubin  05/28/23 04:09  Negative  02/15/23  See Comment Abnormal          Hgb Ur  05/28/23 04:09  Negative  02/15/23  Trace Abnormal          Nitrite  05/28/23 04:09  Negative  02/15/23  Negative          Urobilinogen  05/28/23 04:09  Normal  02/15/23  Normal          Leukocyte Esterase Ur  05/28/23 04:09  Negative  02/15/23  Negative          WBC  05/28/23 04:09  0-5  02/15/23  0-5          RBC  05/28/23 04:09  0-2  02/15/23  6-10 Abnormal          Bacteria  05/28/23 04:09  None  02/15/23  Few Abnormal          Squamous Epithelial  05/28/23 04:09  Few  02/15/23  Few      Diagnostic Results  CT Head W/o IV Contrast    05/28/23 02:22:10  IMPRESSION:  CTA head:  Chronic infarct left occipital and temporal lobe.  Negative for acute intracranial hemorrhage or mass effect   CTA HEAD.  1. Distal left PCA occlusion, which may be chronic. Otherwise  negative for high-grade stenosis or occlusion within the anterior  neck.   CTA NECK.  1. Negative for high-grade stenosis or occlusion.    Dr. was notified of the above findings at 2:32 AM  5/28/2023    Thank you for consulting our team of subspecialty radiologists.  Electronically Signed by:     XR Chest PA or AP Portable    05/28/23 02:14:56  IMPRESSION:  1. No acute findings in the chest.   Thank you for consulting our team of subspecialty radiologists Radiology.     CTA Head/Neck Stroke W/IV Contrast    05/28/23 02:22:10  IMPRESSION:  CTA head:  Chronic infarct left occipital and temporal lobe.  Negative for acute intracranial hemorrhage or mass effect   CTA HEAD.  1. Distal left PCA occlusion, which may be chronic. Otherwise  negative for high-grade stenosis or occlusion within the anterior  neck.   CTA NECK.  1. Negative for high-grade stenosis or occlusion.    Dr. was notified of the above findings at 2:32 AM  5/28/2023    Thank you for consulting our team of subspecialty radiologists