3306 Case Chief Complaint Pt is a 55

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

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

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

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

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

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

• • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological • Diagnosis • Treatment Physical Exam VSBP- 160/94 HR 91 R 18 T 98 Pulse ox 95% General- Pt is well nourished and Ax. Ox 3 Heent- EOMI, PERRLA, no vision changes, no tongue deviation, no sensation loss on face CVRRR 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 GUNo discharge, bleeding MSK- 4/5 MMT on R UE and LE, no gait disturbances TTA T 5 -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 Soc. Hx 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 Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment What do we want to order?

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Labs CBC Chemistry VDRL B 12, Folate Sed rate

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment CBC 13. 9 g/dl 10. 6 139 41. 5 Chemistry 137 103 4. 0 27 14 155 1. 7

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

Thank you! • Questions, comments, concerns?