ED note by Dr. on 6/9/22: "Date:  6/9/2022 Means of arrival:  ambulance History obtained from: patient History limited by: mental status   Chief Complaint:  Altered Mental Status   HISTORY OF PRESENT ILLNESS   Patient, is a 54 y.o. male who presents to the Emergency Department complaining of altered mental status. The patient states that his last known well time was on 6/8/22 at 19:00. The patient states that he woke up this morning with lower extremity cramping, dizziness, and feeling disoriented. The patient states that this has occurred in the past, but not to this extent. The patient states that he felt "fine" mentally last night, but he notes that he was increasingly lethargic. The patient states that he called the EMS dispatcher this morning for transport, but he now states that he does not remember calling or talking to anyone. The patient states that he has been having difficulty with his short term memory for the past few years, and he states that he has had imaging performed on his brain in the past for this condition. The patient states that he has not been diagnosed with a specific abnormality related to his brain or memory that he can recall. The patient states that he is currently being treated for anxiety at this time as well, and he notes that he has had issues related to his heart for the past several years as well. The patient has a documented NSTEMI that he does not recall, and he notes that he as had a TIA/CVA in the past as well. The patient denies symptoms of nausea, vomiting, diarrhea, syncope, chest pain, abdominal pain, shortness of breath, and any urinary or bowel issues."  H&P notes by Dr. on 6/9/22: Date of Admission:  6/9/2022   Chief Complaint:  Altered Mental status.     HPI: Patient is a 54 y.o., male who presents with altered mental status.  He woke up early this morning dizzy, disoriented.  He was feeling fine last night.  He call EMS and was brought to hospital for mental status change.  At this time patient does not remember calling EMS.  He admits to having short-term memory loss for quite some time. He knows where he is right now but unable to remember why and how he came here.  No headache, vision changes, nausea, vomiting, fever.  No chest pain, shortness of breath, cough. History of TIA, non STEMI per chart.  Unable to give any history about this. No other complaints.   Assessment/Plan:    1. Stroke-like symptoms.  Mental status change.  TIA versus embolic CVA.  MRI brain ordered.  Neurology consulted.  Neuro checks.  Echocardiogram.  Physical therapy consulted.  Continue aspirin, Plavix, Lipitor.  Ordering MRI brain, EEG. 2. Hypertension.  Elevated.  Continue Imdur, labetalol, lisinopril.  Monitor vitals.  Add HCTZ if needed. 3. Coronary artery disease.  Continue aspirin, Plavix, labetalol, Lipitor, Imdur. 4. Anxiety/depression.  Continue Lexapro with Klonopin as needed. 5. Acid reflux disease.  Continue Pepcid. "  Consult note by Dr. on 6/9/22:    Date of service: 6/9/2022   Chief Complaint: Confusion, altered mental status   History of Present Illness:    History was obtained from a review of the electronic record and discussion with the patient and family.  Patient is a 54 y.o. male with PMH significant for HTN, anxiety, NSTEMI, TIA who presented to the ED early this morning c/o confusion, altered mental status. Last known normal was prior to bed which he feels may have been 2300 6/8/22 but he is unsure exact time. Reports he woke up in the middle of the night, around 1300 and got a drink of water, thought he went back to bed. Per EMS, he had called EMS twice. He does not remember calling or EMS arrival. He remembers being carried down the stairs in the the stretcher. Admits to similar episodes starting about 4 years ago, increasing in frequency in the last 2 years. He has been evaluated in the hospital a few times with brain imaging and extensive lab workup. He notes these episodes primarily occur either right after he wakes up or in the middle of the night. Has sleep study in the past showing mild OSA, wears Oura ring now, no CPAP. He has previously been diagnosed with TIA and NSTEMI and has been following with Cardiology and his PCP for additional workup. He has had a cardiac event monitor and now has an ILR, no episodes of Afib recorded. He has also had a cardiac cath but no intervention was indicated. He has been taking ASA 81 mg daily, Plavix 75 mg daily and atorvastatin 80 mg qhs and has been compliant with his medications. CT brain w/o contrast was negative for acute abnormality, showed punctate regions of hyperdensity thought to be blood products vs. Hemorrhages vs. emboli. CTA head and neck shows mild intracranial atherosclerosis, will need MRI for further evaluation, pending. UA was positive for fentanyl, pt denies EtOH or illicit drug use. Admits to smoking 0.5ppd for the last several years.   Today he continues to have some disorientation, mild confusion about the events of last night/this morning. He also admits to frontal headache, mild, bilateral leg cramping and tongue pain, feels he may have bit it last night. He has never had tongue pain or leg cramping after one of these episodes. He denies dizziness.    Works as a librarian in another state for an agency.  And: "Assessment and Plan:   1) transient neurological episodes in sleep as well is awake, a total 5-7 episodes, MRI of the brain and CT angiogram head and neck showing concern for acute small subarachnoid hemorrhage which could be traumatic, patient is complain of some tenderness over the left side of the head,. Labs do show elevated WBC, will get prolactin level and CK as well as EEG and MRI brain w/w/o contrast to rule out structural abnormality, possible stroke. Would also recommend ILR interrogation while inpatient to evaluate for possible arrhythmia.    Recommendations:  - MRI Brain w/wo contrast showed acute subarachnoid hemorrhage which could be from a trauma during having the episode - EEG pending -will start Keppra 750 mg twice daily -hold off any antiplatelet and DVT prophylaxis for now -repeat CT brain today to ensure stability of hemorrhage  - prolactin, CK - consider ILR interrogation, Cardiology consult - may work with PT/OT as tolerated. - will continue to follow, please call Neurology with any questions   Greater than 50% of time spent discussing the pathology and coordination of care.   I independently of the faculty provider spent a total of 40 minutes in direct/indirect care of this patient including initial evaluation, review of laboratory, radiology, diagnostic studies, review of medical record, order entry and coordination of care.    6/9/2022, 09:03     I personally saw and evaluated the patient as part of a shared service with an APP.   My substantive findings are: Patient is a 54-year-old gentleman who presents to the hospital after having an episode of confusion overnight and altered mental status.  Patient says that he has had recurrent similar episodes.  Mostly happen during the night but has also happen during the day.  Patient had a CT angiogram head and neck which showed concern for possible small subarachnoid hemorrhage which was confirmed on MRI brain with and without contrast.  Patient is unsure but could have had head trauma during this episode as he has some head tenderness on the left.  Patient complains of mild headache.  Considering patient having recurrent episodes and now having subarachnoid hemorrhage, will start patient on Keppra 750 mg twice daily.  Will get EEG to evaluate for any interictal discharges.  Will check serum CK and prolactin.  Will check echocardiogram and considering patient has a loop recorder, can be interrogated to evaluate for any AFib or any arrhythmia during this episode.  Avoid any antiplatelets and any anticoagulants at this time.  Will repeat CT brain dated today at 6:00 p.m. to ensure stability.  Continue blood pressure control with goal blood pressure systolic 120-160.  Please call Neurology for any questions."