3/3/06 Case

Chief Complaint Pt is a 55 y/o caucasion male who presents with right-sided weakness that started last night.

What questions do we want to ask this patient?

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment History of Present Illness Pt is a 55 y/o c male with history of TIA, hypercholesterolemia and smoking history who presents with right-sided weakness. He states that this began upon waking up at around 1:30 am. He noticed that he was unable to maintain balance and was disoriented and was slurring his words. He noticed that something was different and came to the emergency room. This happened before, about 5-6 years ago, but only lasted about 20 minutes. He states he began feeling better around 4-5 am. Initially he had trouble swallowing but this has since resolved. During the episode he denied any chest pain, palpitations, lightheadedness or vertigo. He does note that he drank 5-6 beers, which is unusual for him. He also denies seizure, bowel or bladder incontinence or lip lacerations.

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Past Medical History TIA in 2000 GERD Hypercholesterolemia Kidney stones BPH Sx: Left leg

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Medications Zantac Prilosec ASA Flomax Allegra Celebrex

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Allergies Residents who ask too many questions

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Social History 40 pack year smoking history Occasional alcohol

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Family Medical History Paternal grandmother had a CVI at 60

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Review of systems General: weight change, fever, chills, weak, slurring words Head: headache, nasuea, vomitting Respiratory: SOB, wheeze, no cough or URI Cardiac: HTN, murmurs, hx angina, palpitations GI: appetite, n/v, incont., no const/diarrhea, frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no dyspareunia, no discharge MSK: muscle weakness, flank pain, muscle cramps, right sided weakness not involving face Neuro: parasthesias, loss of sensation Psychiatric- Pt is not anxious or depressed

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Physical Exam VS- BP- 160/94 HR 91 R 18 T 98 Pulse ox 95% General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes, no tongue deviation, no sensation loss on face CV- RRR w/o murmurs or rubs, clicks or gallops RESP- Clear to auscultation bilaterally, no wheezes, rales or crackles Abdomen- Soft, NT, no rebound, ND, no masses GU- No discharge, bleeding MSK- 4/5 MMT on R UE and LE, no gait disturbances TTA T5-8 on left EXT- No edema, pulses b/l, Neuro-¾ DTR on Right side, ftn intact, mild sensation loss to touch and temperature on right side of body, negative hoffman, CN II-XII intact Skin- No jaundice

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Differential Metabolic Hypoglycemia Tissue Stroke Cancer Vascular Carotid stenosis Migraine? Infectious Syphilis Drugs Alcohol (Wernike)

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment What do we want to order?

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Labs CBC Chemistry VDRL B12, Folate Sed rate

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment CBC g/dl Chemistry

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Chest X-ray No flattening of diaghram Subcostal angles clear No evidence of pneumonia EKG NSR CT Brain No bleed, infarct or mass shift

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Diagnosis 1.Pt is a 55 year old caucasion male with right- sided weakness, starting today and improving, most likely TIA but must r/o CVI On ASA Will add Plavix 75mg daily Counseled patient about smoking cessation Lipid panel 2.Gerd Zantac 150mg bid

Thank you! Questions, comments, concerns?