Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on July 24, 2023 14:08 EDT   Verified By: MD on July 24, 2023 14:08 EDT   Encounter Info: Hospital, Observation, 07/24/23 -     * Final Report *        Chief Complaint   L sided weakness  History of Present Illness/Subjective     Patient is a 77 year old man who presents to the ER w/ L sided weakness and numbness. The patient states that his symptoms began about 5 to 6 hours prior to arrival. He reports no prior h/o stroke. He denies any fever, chills, NVD. Upon arrival to the ER his vitals were stable. Labs were unremarkable. CT head showed no bleeds. CTA head/neck showed severe stenosis bilaterally of the posterior cerebral arteries. MRI brain showed an acute infarct of the posterior limb of the R internal capsule. EKG showed NSR. Neurology was consulted and recommended admission for further w/u. Patient was subsequently admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.4 °C (Oral)  TMIN: 36.1 °C (Oral)  TMAX: 36.4 °C (Oral)  BP: 143/100  HR: 73 (Monitored)  RR: 18  SpO2: 98%  Oxygen Therapy: Room air  Oxygen Flow Rate: 0 (L/min)  WT: 72.2 kg  BMI: 24.9   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    72.2 kg    07/24/23  Previous Daily Weight:    72.2 kg    07/24/23  BMI:    24.9    07/24/23    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    170.2 cm    07/24/23        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: LUE and LLL extremity weakness Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan     Patient is a 77 year old man admitted w/ acute CVA.      1. Left arm weakness   R29.898  -See problem #3      2. Left leg weakness   R29.898  -See problem #3      3. Right-sided cerebrovascular accident (CVA)   I63.9  -Neurology consulted  -Statin and ASA  -A1c, lipid panel  -Permissive HTN for 24 hours  -PT OT ST  -TTE  -Telemetry      4. Hyperlipidemia   E78.5  -Continue statin       5. Gastroesophageal reflux   K21.9  -Continue PPI        Code Status   Resuscitation Status - Ordered    -- 07/24/23 14:00:00 EDT, Full Code   Chronic Problem List    Constipation  Gastroesophageal reflux  Hyperlipidemia  Insomnia  Left inguinal hernia  Procedure/Surgical History  ?colonoscopy (2003) ?Hemmorhoids (1969)     Medications   Home Medications (8) Active  Ambien 5 mg oral tablet 5 mg = 1 Tablet, PRN, Orally, At Bedtime  docusate sodium 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  docusate sodium 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  Lipitor 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Metamucil 1.7 GM, Orally, Daily  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Vitamin B12 100 mCg oral tablet vitamin, Orally  vitamin E , Orally, Daily  Active Scheduled Inpatient Medications  aspirin, Tab, Chewable, 81 mg, Orally, ONCE, Start: 07/24/23 14:00:00  aspirin, Tab, Chewable, 81 mg, Orally, Daily, Start: 07/25/23 09:00:00  atorvastatin, Tablet, 80 mg, Orally, At Bedtime, Start: 07/24/23 21:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 07/24/23 14:00:00    One-Time Medications Given 07/23/23 00:00:00 TO 07/24/23 14:02:39  None Reported  PRN Medications (0600 - 0559) from 07/23 - 07/24  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. Stopped age 32 Years.  Family History   Heart attack: Father and Son.  Hypertension: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (07/24/23 05:21:00)  RBC: 4.88 million/cumm (07/24/23 05:21:00)  Hgb: 14.8 GM/dL (07/24/23 05:21:00)  Hct: 43 % (07/24/23 05:21:00)  MCV: 88 fL (07/24/23 05:21:00)  MCH: 30.4 pg (07/24/23 05:21:00)  MCHC: 34.5 GM/dL (07/24/23 05:21:00)  RDW: 14.1 % (07/24/23 05:21:00)  Platelet: 220 k/cumm (07/24/23 05:21:00)  MPV: 7.2 fL (07/24/23 05:21:00)  Neutrophils %: 50 % (07/24/23 05:21:00)  Lymphocytes %: 37 % (07/24/23 05:21:00)  Monocytes %: 8 % (07/24/23 05:21:00)  Eosinophils %: 3 % (07/24/23 05:21:00)  Basophils %: 1 % (07/24/23 05:21:00)  Absolute Neutrophil: 3.8 k/cumm (07/24/23 05:21:00)  Absolute Lymphocyte: 2.8 k/cumm (07/24/23 05:21:00)  Absolute Monocyte: 0.6 k/cumm (07/24/23 05:21:00)  Absolute Eosinophil: 0.3 k/cumm (07/24/23 05:21:00)  Absolute Basophil: 0.1 k/cumm (07/24/23 05:21:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (07/24/23 05:21:00)  Potassium SerPl QN: 4 mmol/L (07/24/23 05:21:00)  Chloride SerPl QN: 107 mmol/L (07/24/23 05:21:00)  Carbon Dioxide SerPl QN: 26 mmol/L (07/24/23 05:21:00)  Anion Gap: 8 mmol/L (07/24/23 05:21:00)  BUN SerPl QN: 11 mg/dL (07/24/23 05:21:00)  Creatinine SerPl QN: 1.28 mg/dL (07/24/23 05:21:00)  Estimated GFR (CKD-EPI, no race): 58 mL/min/1.73m2 Low (07/24/23 05:21:00)  Estimated CRCL (CG): 47 mL/min Low (07/24/23 05:21:00)  Glucose SerPl QN: 100 mg/dL High (07/24/23 05:21:00)  Calcium Total SerPl QN: 9.2 mg/dL (07/24/23 05:21:00)  Magnesium SerPl QN: 1.9 mg/dL (07/24/23 06:53:00)  Troponin-I High Sensitivity: 4 ng/L (07/24/23 05:21:00)  Gluc-Strip, POC: 99 mg/dL (07/24/23 05:35:00)  Coagulation:  PT: 11.9 seconds (07/24/23 05:21:00)  INR: 1.04 (07/24/23 05:21:00)  aPTT: 30.3 seconds (07/24/23 05:21:00)  All Other Labs:  Hep C Ab QL: NON-REACTIVE (07/24/23 05:38:00)  COVID 19 Specimen Source: Nasopharyngeal (07/24/23 11:17:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (07/24/23 11:17:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 07/24/2023 05:39 - CT Head Stroke W/O IV Contrast  IMPRESSION: 1.  No acute intracranial abnormality.2.  Severe small vessel ischemic diseaseThank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XRAY with any questions.    07/24/2023 05:42 - CTA Head/Neck Stroke W/IV Contrast  IMPRESSION: CTA HEAD.1.  No large vessel occlusion2.  High-grade stenosis of the proximal posterior cerebral arteriesbilaterallyCTA NECK.1.  The major arteries of the neck are widely patent.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XRAY with any questions.    07/24/2023 08:02 - MRI Brain W/O IV Contrast  IMPRESSION:  1.  Acute small infarction within the posterior limb of rightinternal capsule along the right lateral thalamus.2.  Chronic volume loss with moderate chronic microvascular ischemicdisease.Results were communicated and receipt was documented in the Reporting System.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XRAY with any questions.             Signature Line Electronically Signed on 07/24/23 14:08 EDT ________________________________________________________ MD