Caso 282

CASO HIPOTETICO 2 82 M

Chief Complaint

Date: 09/15/21

Time: 09:25

Chief Complaint:

Falling due to legs weakness

Source: Family (daughter)

Accompained by:: daughter)

- History of Present Illness

HPI:

82 y/o male with PMHx of HTN, DM, Renal disease and Stroke is brought to ER by EMS accompanied bye her daughter after falling and hitting the back of the head due to legs weakness when he tries to get up from his walker. Daughter states weakness began last Friday and he had to start using his walker.

- Allergies

Allergies/Adverse Reactions:

Allergies

Allergy/AdvReac Type Severity Reaction Status Date / Time

JUEYES METFORMIN Allergy Swelling Uncoded 09/14/21 20:25

of

Lip/Tongue/Throat

- Home Medications

Home Medications:

Home Medications

Medication Instructions Recorded Confirmed Type

Amlodipine Besylate [Norvasc] 1 tab PO DAILY 09/14/21 09/14/21 History

Humulin N 20 unit SUB-Q BEFORE BREAKFAST 09/14/21 09/14/21 History

Losartan Potassium [Losartan 50 mg PO DAILY 09/14/21 09/14/21 History

Potassium 50 mg Tablet]

Simvastatin [Simvastatin 40Mg 40 mg PO DAILY 09/14/21 09/14/21 History

Tablet]

- Travel Risk - Coronavirus

Travel Risk: No

Contact Risk: No

Has patient experienced symptoms?: No

Past Medical History

- Information

Attestation statement: The following information was validated with the patient or family.

Source: Obtained From Family

Accompained name: DAUGHTER

- Past Medical History

Medical History: CVA, Diabetes, Hypertension, Renal Disease

Surgical History Male: No Surgical History

Psychiatric History: No Psych History

In the past week, have you been having thoughts about killing yourself?: No

- Family History

Family History: Diabetes, Hypertension

- Social History

Smoking Status: Never Smoker

Alcohol Use: No

Alcohol Intake: Former

Sustance Use: No

Review of Systems

- Constitutional

Constitutional: Report: Weakness

- Eye

Eyes: Report: No symptoms reported

- Ear

Ear: Report: No Symptoms Reported

- Nose, Mouth and Throat

Nose, Mouth and Throat: Report: No Symptoms Reported

- Breast

Breast: Report: No Symtoms Resorted

- Cardiovascular

Cardiovascular: Report: High blood pressure, Other (distant heart sounds)

- Respiratory

Respiratory: Report: No Symptoms Reported

- Gastrointestinal / Abdominal

Gastrointestinal/Abdominal: Report: Constipation

- Genitourinary

Genitourinary Male: Report: No Symtoms Reported

- Musculoskeletal

Musculoskeletal: Report: Muscle weakness

- Skin

Skin: Report: No Symptoms Reported

- Neurological

Neurological: Report: Abnormal gait, Focal weakness, Gait disturbance, Speech disturbance, Speech slurred, Stroke, Weakness, Weakness lower extremity, Weakness upper extremity

- Psychiatric

Psychiatric: Report: No Symptoms Reported

- Endocrine

Endocrine: Report: No Symptoms Reported

- Hematology / Lymphatic

Hematologic/Lymphatic: Report: No Symptoms Reported

- Immunology / Allergies

Immunology/Allergies: Report: No Symptoms Reported

- All Other System

Report: Reviewed and Negative

Physical Examination

- Measurement

Vital Signs:

Last Vital Signs

Temp 36.7 C 09/14/21 20:21

Pulse 71 09/14/21 20:21

Resp 18 09/14/21 20:21

BP 143/70 H 09/14/21 20:21

Pulse Ox 97 09/14/21 20:21

Height & Weight:

Height 5 ft 2 in

Weight 58.967 kg

- General Exam

General Condition: Oriented x3, Awake, Alert, Active

Physical Exam General Appearance: Comfortable, Cooperative, No Pain

Physical Exam General Nutrition: Normal Weight

- Head Exam

Head Exam: Normal Exam

- Eyes Exam

Physical Exam Eyes: Normal Appearance, EOMI Abnormal (delay )

- ENT Exam

Physical Exam ENT: Normal Exam

- Ear Exam

Physical Exam Ears: Normal Exam

- Nose Exam

Normal Exam

- Mouth Exam

Physical Exam Mouth: Normal External Inspection

- Neck Exam

Normal Inspection, Normal Position, Non-Tenderness, No Lymphadenopathy, No Thyromegaly, Non Jugular Vein Distention

- Thyroid Exam

Physical Exam Thyroid: Normal Inspection

- Cervical Lymph Node Exam

No Lymphadenopathy

- Chest Exam

Physical Exam Chest: Normal Inspection

- Respiratory Exam

Respiratory Exam: Normal Expansion, Normal Lung Sounds, Normal Respiratory Effort, No Respiratory Distress, Chest No-Tenderness

- Cardiovascular Exam

Normal Heart Sounds (distant )

Peripheral Pulses: 2+: Carotid Right, Carotid Left, Radial Left, Radial Right, Dorsalis Pedis Left, Dorsalis Pedis Right, Posterior Tibialis Left, Posterior Tibialis Right

- GI/Abdominal Exam

Flat, Soft, Diminished Bowel Sounds

- Extremities Exam

Other (Upper limbs weakness Rt>Lt)

General: Normal Inspection

- Upper Extremity Exam

Shoulder Exam: Normal Inspection

Arm Exam: Normal Inspection

Elbow Exam: Normal Extension

Forearm/Wrist Exam: Normal Inspection

Hand Exam: Normal Inspection

- Lower Extremity Exam

Upper Leg: Other (Weakness rt>lt)

Knee: Other (Weakness rt>lt)

Ankle: Other (Weakness rt>lt)

Lower Leg: Other (Weakness rt>lt)

Leg Edema: None

Foot/Toe: No Edema

- Neurological Exam

Neurologic Exam: Normal Mood / Affect, Oriented x3, Alert, Motor Deficit, Other (brocca aphasia )

Patient Oriented To: Person, Place

Speech: Expressive Aphasia, Garbled, Slurred

Motor strength: LLE 3/5, LUE 3/5, RLE 1/5, RUE 2/5

Cerebellar Function: Abnormal finger to nose (bilateral)

- Glasgow Coma Scale

(4) Open Spontaneously

Best Verbal Response (Glasgow): (5) Oriented

Best Motor Response: (6) Obeys Commands

Glasgow Total: 15

- Psychiatric Exam

Normal Affect, Normal Mood

- All Other System

All Other System: Are not pertinent at the moment

Diagnosis Impression

(1) CVA (cerebral vascular accident)

Code(s): I63.9 - Cerebral infarction, unspecified Status: Acute

Qualifiers:

CVA mechanism: thrombosis Laterality of affected vessel: unspecified

(2) Acute focal neurological deficit

Code(s): R29.818 - Other symptoms and signs involving the nervous system Status: Acute

- Assessment and Plan

Assessment and Plan:

82 y/o male with PMHx of HTN, DM, Renal disease and Stroke is brought to ER by EMS accompanied bye her daughter after falling and hitting the back of the head due to legs weakness yesterday. Head CT wo contrast shows no evidence of hemorrhages , Right basal ganglia and frontal corona radiata subacute or chronic infarct. Small cystic structure in the left side of the pons may relate to a perivascular space or chronic lacunar infarct. Moderate chronic white matter small vessel disease and cerebral atherosclerosis. Pertinent labs results below shos Cr. 2.86, BUN 38 and glucose 110. Vital signs pertinent for BP 143/70. Physical examination shows weakness of upper and lower extremities RT>LT, expressive aphasia and grip myotonia. Patient admitted with diagnosis of Recurrent ischemic stroke/ acute ischemic stroke. Will f/u with Brain MRI, Carotids ultrasound, heart echocardiography.

Laboratory Tests

09/14/21 09/14/21

22:30 22:30

RBC 4.57 L

Hgb 12.3 L

Hct 39.4 L

MCHC 31.2 L

Neut # (Auto) 6.91 H

Immature Gran # (Auto) 0.04 H

BUN 38 H

Creatinine 2.86 H

Glucose 110 H

- Labs

09/14/21 22:30

[Image 0]

09/14/21 22:30

[Image 1]

Labs Result:

Coagulation Labs

PT 11.6 Secs (9.1-12.1) 09/14/21 22:30

INR 1.009 09/14/21 22:30

APTT 28.7 Secs (25.3-38.0) 09/14/21 22:30

Abnormal lab results

09/14/21 09/14/21 Range/Units

22:30 22:30

RBC 4.57 L (4.63-6.08) X10^6/uL

Hgb 12.3 L (13.7-17.5) g/dL

Hct 39.4 L (40.1-51.0) %

MCHC 31.2 L (32.2-36.5) g/dL

Neut # (Auto) 6.91 H (1.56-6.13) X10^3/uL

Immature Gran # (Auto) 0.04 H (0.00-0.03) X10^3/uL

BUN 38 H (9-20) mg/dL

Creatinine 2.86 H (0.66-1.25) mg/dL

Glucose 110 H (74-106) mg/dL

Admission Note

- Admission Information

Date of Admission: 09/15/21

Time of Admission: 10:32

Admission Diagnosis: Recurrent ischemic stroke / acute ischemic stroke

Admission Note:

82 y/o male with PMHx of HTN, DM, Renal disease and Stroke is brought to ER by EMS accompanied bye her daughter after falling and hitting the back of the head due to legs weakness yesterday. Head CT wo contrast shows no evidence of hemorrhages , Right basal ganglia and frontal corona radiata subacute or chronic infarct. Small cystic structure in the left side of the pons may relate to a perivascular space or chronic lacunar infarct. Moderate chronic white matter small vessel disease and cerebral atherosclerosis. Pertinent labs results below shos Cr. 2.86, BUN 38 and glucose 110. Vital signs pertinent for BP 143/70. Physical examination shows weakness of upper and lower extremities RT>LT, expressive aphasia and grip myotonia. Patient admitted with diagnosis of Recurrent ischemic stroke/ acute ischemic stroke. Will f/u with Brain MRI, Carotids ultrasound, heart echocardiography.

Education Given on Admission: Diagnosis, Treatment, Medications, Procedure

Orientation to: Patient, Daugther

- Vaccine

Hx Influenza Vaccination: No

Hx Pneumococcal Vaccination: No

Hx COVID Vaccination: Yes

Admission Orders

- Admission Orders

09/15/21 08:50

Admit as Inpatient [ADMISSION] Routine

09/15/21 08:58

MR head/brain wo con [MR] Stat

09/15/21 08:59

CA echo transthoracic complete Stat

09/15/21 09:00

US carotid duplex BI [US] Stat

09/15/21 Lunch

NPO Diet [DIETARY]

09/16/21 05:00

BMP [Basic Metabolic Panel] [CHEM] DAILY

CBC [Complete Blood Cell Count] [HEME] DAILY

09/17/21 05:00

BMP [Basic Metabolic Panel] [CHEM] DAILY

CBC [Complete Blood Cell Count] [HEME] DAILY

09/18/21 05:00

BMP [Basic Metabolic Panel] [CHEM] DAILY