Identifying Data:
Full Name: Mr. H
Address: Ozone Park, NY
Date of Birth: March 2nd, 1963
Date & Time: June 16th, 2020
Location: Queens Line Medical Center, Ozone Park, NY
Religion: Refused to answer
Source of Information: Self
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “I’m here for post hospitalization follow up”.
HPI:
Mr. H is a 57-year-old male patient with a PMHx of benign paroxysmal positional vertigo, HTN, chronic sinusitis, BPH and currently a smoker is here today for a follow up. Two weeks ago, Mr. H had an episode of transient ischemic attack and was hospitalized for 2 days. Patient stated that he was with his wife in his backyard having breakfast and suddenly he noticed that his left upper arm went numb. A few seconds later his left forearm also went numb and then his tongue started to feel heavy. He continued his conversation with his wife and his wife noticed that his speech became slurred and was not making any sense. That’s when his wife decided to call EMS and before they got there Mr. H took 2 pill of aspirin, 81mg each. Once EMS arrived at his house, Mr. H started to feel better but went to ER regardless for further evaluation. Patient states this has never occurred to him before and denies family history of strokes. Patient denies, headache, ataxia, loss of strength, change in cognition, mental status, fever, chill, N/V, diarrhea, constipation, recent trauma to the head, chest pain, shortness of breath or palpitations.
Past Medical History:
Present illnesses – HTN x 4 years; benign paroxysmal positional vertigo x 3 years; BPH x 5 years; chronic sinusitis x 1 year.
Past medical illnesses – Otitis Media when he was a child.
Hospitalizations: Was hospitalized for 2 days due to TIA.
Immunizations- Up to date.
Screening tests and results- colonoscopy done in 2019- benign.
Past Surgical History:
Denies past surgical history.
Medications:
Amlodipine PO, 10 mg once a day for HTN, last done last night.
Losartan PO, 50 mg once a day for HTN, last done last night.
Aspirin PO, 81mg once a day, part of dual-antiplatelet therapy for prevention of stroke.
Clopidogrel (Plavix), 75 mg orally once a day, part of dual-antiplatelet therapy for prevention of stroke.
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, cancer, strokes.
Social History:
Denies use of alcohol.
Patient states he is a smoker. He’s been smoking for 30 years about half a pack per year and has a pack year of 15. Denies use of illicit drug use.
Travel- Has not recently traveled anywhere.
Sexual Hx- Sexually active with his wife. No past history of STD’s, HIV, or any other sexually transmitted diseases.
Review of Systems:
General: denies loss of appetite, fever, recent weight loss or gain, generalized weakness/fatigue, or night sweats.
Head – Denies headaches or head trauma.
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2019 – does not know his visual acuity.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur
Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Nervous – Patient recently had a TIA which resolved itself within 15 mins with no complications and spent 2 days in the hospital. Denies headaches, ataxia, loss of strength, change in cognition / mental status, loss of consciousness.
Physical exam:
General: Pt is alert and oriented x3, well dresses, no apparent distress and responsive to verbal commands.
Vital Signs: BP: R L
Seated 122/85 130/90
Supine 125/90 120/80
R: 16/min unlabored P: 74, regular
T: 99.0 degrees F (oral) O2 Sat: 97% Room air
Height 5 feet and 11 inches Weight 170 lbs. BMI: 23.7
Head: normocephalic, atraumatic, non-tender to palpation throughout
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;
conjunctiva & cornea clear.
Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU).
Visual fields full OU. PERRL, no accommodation, EOMs full with no nystagmus
Fundoscopy – Red reflex intact OU. Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Thorax & Lungs:
Chest– symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Cognitive assessment
Mini- mental exam:
What year is it: 5/5
Where are we: 5/5
Give names of 3 objects. Ask resident to repeat all 3 then ask them to remember. 3/3
Serial 7’s from 100 to 5 answers or spell the word “world” backwards: 5/5
Ask for the 3 objects named above: 3/3
Test giver points to pencil and watch and the resident names them: 2/2
Repeat the following: “No ifs, ands or buts” 1/1
Follow 3 commands: take paper, fold it in half, put it on the floor” 1/1
Read and obey the following: CLOSE YOUR EYES: 1/1
Write a sentence: 1/1
Copy a design: 1/1
Total score: 30/30
Assessment:
Mr. H is a 57-year-old male patient with a PMHx of benign paroxysmal positional vertigo, HTN, chronic sinusitis, BPH and is a current smoker is here today for a follow up. Two weeks ago, Mr. H had an episode of transient ischemic attack and was hospitalized for 2 days. TIA resolved itself within 15 mins with no complications and patient took 2 aspirin pills (81mg) before EMS came in. Today patient reports no symptoms and physical exam was benign and the patient scored a 30/30 on the mini-mental exam.
Differential Diagnosis:
1) Transient Ischemic Attack: Patient presented with classic symptoms of a TIA and this diagnosis was later confirmed in the ER in Jamaica hospital. Patient needs to be very careful now as TIA could lead to ischemic strokes with more severe outcomes.
2) Ischemic stroke: Symptoms of TIA and ischemic strokes are very similar and they can sometimes be mixed with each other. Our patient did not report any visual changes or symptoms during TIA which is making this diagnosis unlikely as most of the times patient who are having an ischemic stroke will also report visual issues and symptoms.
3) Myocardial Infraction: Although unlikely, we have to consider MI since our patient is a smoker, 57- years old and has a history of HTN.
Plan:
1) Order CBC, CMP.
2) Order CT of the head.
3) Refer to Neurology for further assessment.
4) Order a CT scan of the chest since our patient has been a smoker for 30 years and is still a smoker. Smoking cessation consultation. Offer nicotine patch or nicotine gum or if they would like to start on Chantix.
5) Consult patient on the importance of a healthy diet and exercise to prevent future strokes or TIAs.
6) Continue Amlodipine PO, 10 mg once a day for HTN.
7) Continue Losartan PO, 50 mg once a day for HTN,
8) Continue Aspirin PO, 81mg once a day, part of dual-antiplatelet therapy for prevention of stroke.
9) Continue Clopidogrel (Plavix), 75 mg orally once a day, part of dual-antiplatelet therapy for prevention of stroke.
10) ABCD2 score assessment: 3 points (3.1% of 90-day stroke risk)
Age >60 =0
Blood pressure >140/90= 0
Clinical symptoms (one point of slurred speech and one point for unilateral weakness)= 2
Duration (more than 10 mins)= 1
Diabetes= 0
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
