ED notes from Dr. on 10/3/22: "Date:  10/3/2022 Primary care provider:  MD Means of arrival:  private car History obtained from: patient and husband History limited by: none   Chief Complaint:  Involuntary movements   HISTORY OF PRESENT ILLNESS   Patient, is a 77 y.o. female who presents to the Emergency Department complaining of involuntary movements of the left face, left arm, and left leg that started 3-4 days ago in.  The patient's husband describes these as choreiform type movements and primarily they involve the left upper extremity.  Patient has also been experiencing some slightly decreased sensation on the left side of her face and mild weakness in the left lower extremity.  She denies any vision loss, difficulty swallowing, headache, fever, chest pain, dyspnea, neck pain, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria, hematochezia, and extremity swelling.  The patient's husband has noticed a decrease in her cadence of her speech but no slurred speech.  The patient had been experiencing daily headaches for the last several weeks that vary in intensity but in these last 3-4 days she has not had any headache.  The patient received both a flu vaccination and COVID booster approximately 10 days ago.  Since the onset of her symptoms the patient's husband has increased her prednisone dose from 5-10 mg daily and discontinued her spironolactone.  Otherwise her not been any other medication changes recently."  H&P note from Dr. on 10/3/22: "Patient Date of Admission:  10/3/2022  Date of Service:  10/3/2022    PCP: MD Chief Complaint:  Stroke like symptoms   HPI: Patient is a 77 y.o., female with a history of essential hypertension who presents with left-sided weakness that began about 5 days ago.  Weakness initially started in the left upper extremity and slowly spread to left lower extremity and left side of face as well.  She is unable to hold anything with her left upper extremity.  She is able to walk although she has some difficulty with her left leg.  She has also had some involuntary, choreiform movements of left arm and leg that started 3 days ago.  She also has slightly decreased sensation over the left side of her face.  She has had some slurring of speech as well over the past few days.  She has a headache occasionally but has not had 1 today.  She denies fever/chills, nausea/vomiting, diarrhea, dysuria.  She has had a history of rheumatic fever as a child. She received a flu vaccination and COVID-19 booster approximately 10 days ago.   In the ED, CT angiogram negative for acute stroke.  Lab work significant for elevated creatinine of 1.32.  Admitted for further workup and management.   COVID-19 vaccination status:  Received vaccine x3 and booster x1. COVID-19 test:  Negative today. " Assessment/Plan:  Patient is a 77 y.o., female who presents with the following:   1. Stroke-like symptoms  Choreiform movements -CT angiogram shows atherosclerotic changes involving right carotid bifurcation with deep ulceration, no stenosis.  No acute infarcts noted.  Will order MRI. -had history of rheumatic fever as a child.  No documented valvular heart disease. -will order HbA1c, lipid panel, TSH, vitamin B12, folate, syphilis antibodies, echocardiogram. -will start on aspirin 81 mg, atorvastatin 40; consult Neurology, PT/OT.  Aspiration screening ordered.   2. Acute kidney injury  -baseline creatinine 0.9 earlier this year, currently 1.32. -will start on normal saline at 100 cc/hour, order urine protein/creatinine, monitor renal function, discontinue spironolactone.   3. Essential hypertension -discontinue spironolactone, start on low-dose Coreg with holding parameters, will adjust dosage as needed.   4. Rheumatoid arthritis -on infliximab and weekly injections of methotrexate.   5. Macrocytosis without evidence of anemia  -ordered vitamin B12 and folate levels.   DVT PPx:  SCDs for now. Code Status:  Full code."  Consult note from Dr. on 10/4/22: "Patient   Date of service: 10/4/2022  Consulting Physician:    Chief Complaint: Left sided weakness & uncontrollable movements   History of Present Illness:    History was obtained from a review of the electronic record and discussion with the patient and family.  Patient is a 77 y.o. female presents w complaints of L facial sensation changes (w/o weakness), LUE weakness w/ constant chorea, and LLE weakness. She states that her symptoms began four days ago. She received a flu vaccine and covid booster ten days ago, which was followed by flu like symptoms. She states that her movement difficulties began in her LUE and evolved to include her face and LE. She denies any current fevers, headaches, speech changes, or behavior changes.    Of note, she normally takes a statin and spironolactone but states she has not taken either of these for the past month. She has recently increased her dose of prednisone from 5 mg to 10 mg." "Assessment and Plan:   1) Patient is a 77-year-old lady was admitted to the hospital after having choreiform movements of the left arm since the last 4 days.  Etiology of her symptoms is currently unclear but the localized to the right basal ganglia/thalamic region, could be vascular due to an acute ischemic stroke versus inflammatory, she does have a history of underlying autoimmune disease and is on treatment for her rheumatoid arthritis Recommendations:  -MRI brain with and without contrast pending - HGA1C pending -750mg Keppra bid to help with the choreiform movements  -continue aspirin 81 mg and Lipitor 40 mg  -based on the MRI reports, will consider treatment with steroids or lumbar puncture -continue PT OT evaluation, Neurology was guided to follow   MED STUDENT  10/4/2022, 09:05   I was present when the student was taking history, performing the exam, and during any medical decision making activities. I personally verified the history, performed the exam, and medical decision making as edited in the student?s note. I agree with the medical student?s note.   MD  10/4/2022, 11:42"  Note from Dr. on 10/5/22: "Reviewed MRI brain with the patient and the husband, not showing any significant acute abnormality, etiology of patient's symptoms are possibly from COVID-19/flu  vaccine induced Chorea movements, will discontinue Keppra as it did not help her, will start Seroquel 25 mg twice a day to see if any improvement, will also give IV Solu-Medrol 500 mg daily for 3 days and then prednisone taper 60 mg for 5 days and then 50 mg, 40 mg, 30 mg, 20 mg, 10 mg for the next 5 days and stop.  I have also referred the patient to ] movement Disorder Clinic for further evaluation.   MD  10/5/2022, 13:16"  Progress note from Dr. on 10/5/22: "  ASSESSMENT AND PLAN:  Primary hospital problem -- abrupt onset of choreoform movement in left upper extremity  CT negative for acute bleed or mass  ASA, statin, beta-blocker  MRI of brain without any evidence of structural damage or acute issue  Dr. and I spoke -- > arrange outpatient high-dose steroids for several days, taper steroids after that  Seroquel for dopamine stimulation for the time being "