Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 30, 2023 18:15  Verified By: MD on January 30, 2023 18:15  Encounter Info: Hospital, Inpatient, 01/30/23 -     * Final Report *        Chief Complaint   Facial numbness  History of Present Illness/Subjective     Patient is a 65 year old man who presents to ER w/ left sided facial numbness and L arm weakness 10 minutes prior to arrival. The patient reports that these symptoms occurred suddenly and that he could not lift his left arm up. Given c/f stroke they went to the ER. Upon arrival there he was hypertensive at 154/82 but the remainder of his vitals were normal. His neurologic deficits resolved shortly after arrival. Labs were WNL. Head CT showed no bleeding. CTA head/neck showed no interveneable lesions. MRI of the brain showed some small acute infarcts in the R frontal lobe. Neurology was consulted and did not recommend TPA as patient's symptoms had resolved. Patient was subsequently admitted to stroke w/u. Upon arrival to to hospital his vitals are stable. He has no new complaints at this time.  Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective     Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan     Patient is a 65 year old man admitted w/ an acute CVA.      1. Acute CVA (cerebrovascular accident)    -Neurology consulted  -Permissive HTN for the next 48-72 hours  -PT OT ST  -Telemetry  -TTE  -Statin and ASA  -TSH, ESR, B12, A1c, lipid panel  -Ensure euglycemia and euthermia       Code Status   Resuscitation Status - Ordered    -- 01/30/23 18:10:00, Full Code   Chronic Problem List    No chronic problems  Procedure/Surgical History  ?colon resection from Crohn's     Medications   Home Medications (4) Active  Restasis   Vitamin C   Vitamin D3 25 mCg (1,000 intl units) oral capsule   vitamin E   Active Scheduled Inpatient Medications  aspirin, Tab, Chewable, 81 mg, Orally, Daily, Start: 01/31/23 09:00:00  atorvastatin, Tablet, 40 mg, Orally, At Bedtime, Start: 01/30/23 21:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 01/30/23 19:00:00    One-Time Medications Given 01/29/23 00:00:00 TO 01/30/23 18:11:06  None Reported  PRN Medications (0600 - 0559) from 01/29 - 01/30  None Reported  Allergies   Flagyl  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Non-contributory  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.4 k/cumm (01/30/23 08:46:00)  RBC: 4.93 million/cumm (01/30/23 08:46:00)  Hgb: 14.8 GM/dL (01/30/23 08:46:00)  Hct: 43.8 % (01/30/23 08:46:00)  MCV: 89 fL (01/30/23 08:46:00)  MCH: 29.9 pg (01/30/23 08:46:00)  MCHC: 33.7 GM/dL (01/30/23 08:46:00)  RDW: 14.5 % (01/30/23 08:46:00)  Platelet: 261 k/cumm (01/30/23 08:46:00)  MPV: 7.3 fL (01/30/23 08:46:00)  Neutrophils %: 64 % (01/30/23 08:46:00)  Lymphocytes %: 27 % (01/30/23 08:46:00)  Monocytes %: 7 % (01/30/23 08:46:00)  Eosinophils %: 2 % (01/30/23 08:46:00)  Basophils %: 1 % (01/30/23 08:46:00)  Absolute Neutrophil: 4.1 k/cumm (01/30/23 08:46:00)  Absolute Lymphocyte: 1.7 k/cumm (01/30/23 08:46:00)  Absolute Monocyte: 0.4 k/cumm (01/30/23 08:46:00)  Absolute Eosinophil: 0.1 k/cumm (01/30/23 08:46:00)  Absolute Basophil: 0 k/cumm (01/30/23 08:46:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (01/30/23 08:46:00)  Potassium SerPl QN: 4 mmol/L (01/30/23 08:46:00)  Chloride SerPl QN: 104 mmol/L (01/30/23 08:46:00)  Carbon Dioxide SerPl QN: 27 mmol/L (01/30/23 08:46:00)  Anion Gap: 8 mmol/L (01/30/23 08:46:00)  BUN SerPl QN: 20 mg/dL (01/30/23 08:46:00)  Creatinine SerPl QN: 1.23 mg/dL (01/30/23 08:46:00)  Estimated GFR (CKD-EPI, no race): 65 mL/min/1.73m2 (01/30/23 08:46:00)  Glucose SerPl QN: 99 mg/dL (01/30/23 08:46:00)  Calcium Total SerPl QN: 9.2 mg/dL (01/30/23 08:46:00)  Alkaline Phos SerPl QN: 37 Units/L (01/30/23 08:46:00)  ALT SerPl QN: 41 Units/L (01/30/23 08:46:00)  AST SerPl QN: 26 Units/L (01/30/23 08:46:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (01/30/23 08:46:00)  Total Protein SerPl QN: 7.1 GM/dL (01/30/23 08:46:00)  Albumin SerPl QN: 4.3 GM/dL (01/30/23 08:46:00)  Troponin-I High Sensitivity: <3 (01/30/23 08:46:00)  Coagulation:  PT: 10.7 seconds (01/30/23 08:46:00)  INR: 0.96 (01/30/23 08:46:00)  aPTT: 26.5 seconds (01/30/23 08:46:00)  Urine Studies:  Color: Yellow (01/30/23 09:42:00)  Clarity: Clear (01/30/23 09:42:00)  Specific Gravity: 1.010 (01/30/23 09:42:00)  pH: 5.0 (01/30/23 09:42:00)  Protein: NEGATIVE (01/30/23 09:42:00)  Glucose: NEGATIVE (01/30/23 09:42:00)  Ketones: NEGATIVE (01/30/23 09:42:00)  Bilirubin: NEGATIVE (01/30/23 09:42:00)  Hgb Ur: TRACE. Abnormal (01/30/23 09:42:00)  Nitrite: NEGATIVE (01/30/23 09:42:00)  Urobilinogen: NormalUro (01/30/23 09:42:00)  Leukocyte Esterase Ur: NEGATIVE (01/30/23 09:42:00)  WBC: None Seen (01/30/23 09:42:00)  RBC: None Seen (01/30/23 09:42:00)  Bacteria: NONE (01/30/23 09:42:00)  Squamous Epithelial: Few (01/30/23 09:42:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (01/30/23 13:08:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/30/23 13:08:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/30/2023 09:34 - CT Head W/o IV Contrast  IMPRESSION:1.   Within normal limits.    01/30/2023 09:39 - CTA Head/Neck WO/W IV Contrast  IMPRESSION:1.   Less than 50 percent smooth narrowing of the M1 segment of theright middle cerebral artery presumably due to atheroscleroticdisease although vasospasm or vasculitis could also give thisappearance.2.  Otherwise essentially normal CTA appearance of cervical andintracranial arterial circulation. No vascular cutoff or intraluminalthrombus. No hemodynamically significant narrowing.    01/30/2023 11:55 - MRI Brain W/O IV Contrast  IMPRESSION:1.   There are couple of ill-defined areas of acute ischemiaprimarily involving subcortical white matter with a small amount ofinvolvement of overlying cortex at the posterior right frontal lobein the region of the precentral gyrus and at the right parietal lobe.There is no associated mass effect. There is a tiny focus ofsusceptibility artifact adjacent to the right parietal white matterinvolvement consistent with either microhemorrhage or cavernoma.2.  There are mild underlying changes of chronic microvasculardisease, greatest at bilateral parietal white matter.             Signature Line Electronically Signed on 01/30/23 18:15 ________________________________________________________ MD