Date of Admission: 10/24/2023   Date of Discharge: 10/27/2023   Issues to be Addressed at Follow-up: -vascular surgery f/u for bilateral carotid artery occlusion -duration of DAPT -duration of permissive hypertension (holding home BP meds at discharge)   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 9/27/2023 to 10/28/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE STROKE DUE TO ISCHEMIA, UNSPECIFIED TYPE AND ARTERY   ? BILAT CAROTID ARTERY STENOSIS   ? TOBACCO USER   ? COVID-19 DISEASE       4/18/22 symptoms started.  4/19/22 home test positive. Patient vaccinated X 2 doses.     4/21/2022 TAV Hx:  Patient has Covid, sick since 4/18/22 with body aches, chills, fever up to 102, headache. Still with congestion and vertigo, as well as myalgias, but is doing a bit better. No dyspnea; no distress noted over the phone. Patient had a positive home test on 4/19/22 (picture uploaded). Was told by employer that a PCR test needed to be formally done, however, they are in the process of changing their protocols.  Patient has no other questions or concerns today. A/P: cont with rest, fluids, supportive measures. Cont with quarantine through 4/28 (WASF already in system).        ? HYPERLIPIDEMIA   ? HTN (HYPERTENSION)           2/24/2021  Patient's blood pressure today was elevated, likely because he was upset, he could not stay quiet for a short period of time, he had apparently worked all night and was tired.   I encouraged patient to continue taking his blood pressure medication on a regular basis.  Return for a blood pressure check at a future visit.  Patient verbalized understanding and importance of controlling his blood pressure.  He described the experience of a recent friend that passed from a sudden heart attack apparently.       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 65 year old man with HTN, HLD, tobacco use, admitted 10/24/23 with stroke, noted to have severe bilateral carotid artery near-occlusion. He was seen by vascular surgery, started on DAPT, atorvastatin, permissive hypertension and plan for carotid endarterectomy. Incidentally noted to have COVID.  Per vascular surgery: "B carotid artery near occlusion with B infarcts and + covid test 10/24   Left side with string sign v. occlusion, significantly more infarcts on left Right side has a string sign He has been loaded with DAPT.   D-dimer is negative which suggests a more chronic process.   Rec: Follow clinically for TIA symptoms - if persist or new symptoms, may need urgent endarterectomy (would be a high risk carotid endarterectomy)   Talked with wife on phone yesterday. She is understandably worried that he will have a stroke while waiting for surgery. D/W her that the timing of carotid endarterectomy in patient is complicated by the severity of his carotid stenoses, positive COVID test and extent of infarcts. He may have an interval cva while waiting for surgery, but the covid dx puts him at risk for being hypercoagulable and the extensive infarcts and near B occlusion put him at risk for reperfusion injury. Weighing the risks, believe operating towards the end of the normal two week window after a CVA or TIA with minor deficits makes the most sense.    Reviewed all of the reasoning above with the patient. Discussed the plan:   11/1: Outpatient ultrasound to see if left ICA is open and f/u in clinic to discuss carotid endarterectomy again   11/6: If left ICA is open, will do left carotid endarterectomy. If it is occluded by ultrasound, will do right carotid endarterectomy. Will need shunt.   Answered all questions. Offered to call pts wife and discuss again. He declined.    Recommend: Permissive hypertension until surgery. DAPT until surgery (and likely will continue afterwards).  Discussed indications and timing of surgery with the Vasc Group. "   I assumed care of the patient on 10/27/23 at which time he was medically ready for discharge home with PCP and vascular surgery f/u.  At the time of hospital discharge patient is feeling well and he is very eager to go home. He will start ASA plavix and atorvastatin, and will stop losartan-HCTZ until directed to restart it. Vascular surgery f/u has been arranged. Return precautions for recurrent stroke were given. He is in agreement with the discharge plan.      PHYSICAL EXAM: BP 154/86  | Pulse 56  | Temp 97.7 °F (36.5 °C)  | Resp 18  | Ht 5' 11"  | Wt 86.6 kg (191 lb)  | SpO2 92%  | BMI 26.64 kg/m²      General appearance - alert, well appearing, and in no distress Mental Status - alert, oriented x 3, argumentative Chest - normal work of breathing, speaking in full sentences, lungs clear Heart - regular rate and rhythm Neurological - motor and sensory grossly normal bilaterally Extremities - no clubbing, cyanosis or edema Skin - warm and dry   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  stroke   Complications: none     Consults:  SURGERY, VASCULAR - INITIAL INPATIENT CONSULTATION. SURGERY, VASCULAR - ONGOING INPATIENT CONSULTATION. HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: Yes - Reason Medication or Counseling not ordered: Patient declined follow-up smoking cessation counseling   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code   DO      Note Details  Author (D.O.) File Time 10/27/2023 12:57 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine  Admit Date 10/24/2023  ED to Hosp-Admission (Discharged) on 10/24/2023  ED to Hosp-Admission (Discharged) on 10/24/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  CAROTID ENDARTERECTOMY Noted 10/26/2023  Hospital Problem List   HYPERLIPIDEMIA  HTN (HYPERTENSION)  BILAT CAROTID ARTERY STENOSIS  ACUTE STROKE DUE TO ISCHEMIA, UNSPECIFIED TYPE AND ARTERY  COVID-19 DISEASE  TOBACCO USER Care Timeline  10/24   Admitted from ED (Observation) 1825 10/27   Discharged 1229  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/27/2023) Medication List at Discharge   aspirin 81 mg Oral DAILY  atorvastatin calcium 80 mg Oral DAILY  clopidogrel bisulfate 75 mg Oral DAILY  nicotine 14 mg/24 hr 1 Patch Transdermal EVERY MORNING