ED note by Dr. on 7/31/22: "Patient   Date of Service: 7/31/2022  Primary Care Doctor: MD Patient information was obtained from patient. History/Exam limitations: none.   Chief Complaint:Vomiting     HPI:   Patient is a 57 y.o. female who presents to the Emergency Department with dizziness and vomiting.  Patient states that she was feeling well yesterday and she was asleep in a proximally 2:00 a.m. awoke to use the restroom she states that when she got up out of bed she suddenly felt very dizzy with a spinning sensation and associated nausea vomiting.  She states that she lays still the symptoms all seem to improve but that any time she moves her head she feels a sense of spinning with vomiting.  She states that her mouth feels dry.  She denies any fever cough chest pain shortness of breath or congestion.  The nurse's triage note states that the patient wants to be checked for COVID but when I spoke with the patient she states that she does not believe that she has COVID and that she is immunized.  She denies any headaches, double vision, blurry vision, chest pain, focal weakness numbness or rashes.  She denies any recent head injuries.  Denies any tinnitus or changes in hearing. " "Impression:   Encounter Diagnoses Name Primary? ? Vertigo Yes ? Nausea and vomiting   ? Elevated troponin       Disposition: pending     Condition on Disposition: Stable"  H&P by FNP on 8/1/22:  Date of Admission:  7/31/2022  Date of Service:  8/1/2022     PCP: MD Chief Complaint:  dizziness   HPI: Patient is a 57 y.o., female with a history of migraines, type II DM, CAD, HTN, HLD, and COPD who presented to the ED for further evaluation of dizziness and vomiting.  Patient states that she was feeling like her normal self yesterday and when she went to sleep but at aproximally 2:00 a.m. she awoke to use the restroom and suddenly felt very dizzy/spinning associated nausea vomiting.  She states that she lays still the symptoms all seem to improve but that any time she moves her head she feels a sense of spinning with vomiting. She admits to gneralized weakness, none unilaterally, and trouble standing/walking but denies headache, facial droop, vision changes, speech changes, recent illness, fever, chest pain, paraesthesias, abdominal pain, urinary symptoms, or diarrhea. Has hx of triple bipass a few years ago but denies hx of stroke.  A CT of her brain today revealed an Asymmetric hypodensity in the left cerebellum suggesting area of evolving infarct. No acute intracranial bleed. Her lab workup is generally unremarkable apart from a trivially elevated trop of 55, no change on repeat a few hours later. UA is negative for infection. Her vertigo has improved after meclazine. NIHSS in the ED= 0. Not a candidate for tpa regardless as she is out of time window. Slightly hypertensive in the 170s, other vss. " "Assessment/Plan:  Patient is a 57 y.o., female who presents with the following:   1. Acute left cerebellar infarct --vertigo improving. NIHSS=0. Out of time window to be tpa candidate regardless  --confirm with MRI --CTA head and neck pending  --stroke orderset initiated, neurology consulted --check updated lipid panel, pending results and further workup continue 80 mg atorvastatin and TriCor  --continue daily low dose aspirin  --updated echo with bubble study  --pt/ot consulted as well per stroke protocol    2. hypercalcemia  --check phos and PTH levels     3. Uncontrolled HTN --elevated today mostly 170s systolic --will allow for permissive HTN for now, continue home metoprolol. Will likely need additional maintenance med   4. Uncontrolled Type II DM  --recent A1C 8.7 --on metformin and trajenta at home --hold oral diabetic meds for now and add ssi coverage with Humalog achs   5. Hx of CAD --s/p CABG  --continue asprin statin,    6. COPD --no acute issues, continue home inhalers    7. Tobacco abuse --pt counseled on smoking cessation    10 Depression and anxiety --continue home Lexapro   11. Hx of migraines --continue home topamax. Takes maxalt at home    DVT PPx: subq heparin  Code Status:  Full Code   DNP,FNP-C"  Consult note by Dr. on 8/2/22:    Date of service: 8/2/2022   Chief Complaint: Dizziness, N/V   Subjective:    History was obtained from a review of the electronic record and discussion with the patient and family.  Patient is a 57 y.o. female with PMH significant for type II DM, HTN, HLD, CAD s/p CABG who presented to the ED 7/31/22 with acute onset dizziness, N/V, admitted for left PICA territory stroke secondary to occluded left PICA. Pt states she feels the same today, denies any vomiting but still notes significant dizziness/nausea with moving her head or posture change. Her daughter is present at bedside. " "  Assessment and Plan:     1) Stroke summary: 57 y/o F with PMH significant for CAD s/p CABG, HLD, HTN, type II DM and tobacco use disorder who presented to the ED 7/31 with acute onset dizziness with N/V. CT brain shows evolving left cerebellar infarction without signs of hemorrhage and CTA head and neck shows occluded left PICA as well as moderate to severe stenosis of the left vertebral artery origin as well as multiple intracranial calcified and noncalcified plaques particularly in the posterior circulation. MRI brain w/o contrast confirms left PICA territory ischemic stroke. Etiology is likely artery to artery embolus due to the left PICA occlusion. TTE with bubble was negative intracardiac shunt, EF 65%. Continue with best medical management with dual antiplatelet therapy with ASA 81 mg and Plavix 75 mg daily x 3 months, with ASA 81 mg daily to continue and high dose statin therapy with atorvastatin 80 mg qhs. She also has significant underlying vascular risk factors with tobacco use disorder and uncontrolled type II DM and will need aggressive glycemic control and smoking cessation to lower her risk factors.    Stroke Etiology: Artery to artery embolus secondary to left PICA occlusion   General Plan:   -Normoglycemia -Normothermia     Blood pressure plan:   -Place pt on telemetry   -BP goal:  - <130/90         Medications:   -Antiplatelet:  ASA 81 mg and Plavix 75 mg x 3 months, then ASA 81 mg daily to continue   -Statin: atorvastatin 80 mg qhs   -DVT ppx: Lovenox 40 mg subq daily       Imaging:  - TTE- 2D echo w bubble - negative for intracardiac shunt, EF 65% - CTA head and neck - L PICA occlusion, moderate to severe stenosis left vertebral artery origin, moderate to severe stenosis right vertebral artery, multiple intracranial calcified and noncalcified plaques -MRI brain - acute left PICA territory ischemic stroke      Lab work:   -LDL 170   -Hemoglobin A1c - 8.7           Diet plan:   - low glycemic index diabetic diet     Consultants:   - Physical therapy, occupational therapy       Activity Level:      - PT/OT     Disposition:  Continue to work with PT/OT, will need outpatient therapy as well. She should follow-up with Neurology clinic with myself or Dr. in 4-6 weeks for re-evaluation.    Stroke Education:    1. Patient was educated that he would benefit from tight control of his vascular risk factors (LDL < 70, BP < 130/90, glycemic control A1c < 7)  2. Patient was educated to call 911 for any acute stroke symptoms (BE FAST- Balance problems, Eyes-blurry vision, double vision, Facial Droop, Arm Weakness, Speech Problems, Syncope, Seizure) 3. Medications: Patient was counseled to take Asprin 81 mg daily / Plavix 75 mg daily / Lipitor 80 mg daily  4. Patient was counseled about the need for follow-up with PCP and in neurology clinic after discharge  5.   Lifestyle: Smoking cessation is vital. We counseled this patient on need to quit smoking and resources to do so. We encourage risk factor treatment and management by pt?s PMD. Patient was educated on Mediterranean diet, exercise, medication compliance   Stroke Education was given verbally to the patient and family member and the teaching was effective and patient and family member in agreement with the plan."