Chief Complaint: Difficulty speaking x 3 days

60 y/o male with a history of HTN, HLD, current smoker (20 pack year), and stroke on 01/23 (no residual deficits) presents to the ED sent by his neurologist due to dysarthria, slurred speech, and numbness for the past 3 days. Patient states that his symptoms have not worsened or gotten better over the past 3 days. He reports that his numbness is predominantly in his right upper extremity and is consistent in nature. Pt does admit that since his stroke in January he has been on both plavix and ASA. He denies any alleviating or aggravating factors and states it is non radiating. Patient denies any facial drop, weakness, tingling, headache, vision disturbances, dizziness, chest pain, SOB, syncope, head trauma, nausea, vomiting, diarrhea, and fever. 

 PMH

• HLD x 12 years controlled medically
• HTN x 15 years controlled medically
• Ischemic Stroke x 5 months controlled medically

PSH

• Pt denies any previous surgeries 
• Pt denies any previous blood transfusions 

Medications

• aspirin 81 MG Tablet, PO QD
• atorvastatin 40 MG Tablet, PO QHS last dose last night 
• clopidogrel 75 MG Tablet, PO QD last dose this morning
• losartan 25 MG Tablet, PO QD last dose this morning
• Denies herbal and OTC use

Family hx

• Pt reports no family h/o HTN, MI, DM, or cancer
• Mother- deceased at age 93 from natural causes
• Father- deceased at age 92 from natural causes 
• 2 children (2 sons)- alive and well

Social hx

• Habits-  Pt. smokes approximately half pack per day x 40 years. Pt. denies illicit drug use. Pt. also denies alcohol and caffeine use. 
• Travel- Pt. denies any recent travel. 
• Marital history- Pt has been married to his wife for over 40 years 
• Sexual history- Pt states he is a heterosexual male in a monogamous relationship with his wife, and no history of any STD’s. 
• Occupational history- Pt is a retired MTA bus driver
• Home situation- Lives with wife, independent IADL and ADL, lives in a 2 story house, able to ambulate up and down stairs.
• Diet- pt diet consists mainly of chicken and rice. 
• Safety measures– Admits to car seat use.

Allergies:

• NKDA
• Denies environmental and food allergies.

ROS:

• General – Denies fever, night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite. 
• Skin, hair, nails – Denies rash, excessive dryness, pigmentations, moles, pruritus, excessive sweating, or changes in hair distribution
• Head – Denies headaches, vertigo, or head trauma, dizziness 
• Eyes – Denies glasses or contact usage, Last eye exam 2022 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus. 
• ENT – Denies deafness, pain, discharge, tinnitus. Denies discharge obstruction, or epistaxis. Last dental exam February 2023. Denies sore throat bleeding gums, sore tongue, mouth ulcers, or voice changes. 
• Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
• Cardio: Denies chest pain, exercise intolerance, PND, and palpitations.
• Respiratory: denies cough, SOB and wheezing.
• GI: Denies abd pain, nausea, vomiting, diarrhea, and constipation.
• GU: Denies polyuria, dysuria, penile discharge, hesitancy, and nocturia.
• MSK: Denies pain, stiffness, joint swelling, and decreased ROM.
• Heme: Denies petechiae, purpura, anemia, and prolonged bleeding.
• Psych: Denies depression, changes in sleep patterns, anxiety, and difficulty concentrating. 
• Endo: Denies weight loss, heat intolerance, cold intolerance, dry skin, and thinning hair. 
• Neuro: See HPI

 PE

• Vitals: BP 152/94 right arm seated, HR 71, RR 17, Temp 36.6 orally, SpO2 97% room air, weight 63.5 kg, height 1.65 m  
• General: Well appearing male not in any acute distress, A&O x 3, cooperative, thoughts & speech coherent.
• Head: normocephalic, atraumatic, non-tender to palpation throughout
• Tongue – Pink; well papillated; no masses, lesions, or deviation.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual fields full OU. PERRL, EOMs intact with no nystagmus
• Neuro: right sided facial and right upper extremity paresthesia. Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout. Romberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis. Reflexes 2+ throughout, negative Babinski, no clonus appreciated No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.
• Cardiac: PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
• Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
• Abd: bowel sounds normoactive in all four quadrants, soft non tender and non distended throughout.
•  MSK/extremities: FROM, non tender to palpation no deformities erythema, ulcerations, or edema present.

NIH Stroke Scale

• Interval: Initial evaluation
• Level of Consciousness: Alert, keenly responsive
• LOC Questions: Answers both questions correctly
• LOC Commands: Performs both tasks correctly
• Best Gaze: Normal
• Visual: No visual loss
• Facial Palsy: Partial paralysis (right)
• Motor Arm, Left: No drift
• Motor Arm, Right: No drift
• Motor Leg, Left: No drift
• Motor Leg, Right: No drift
• Limb Ataxia: Absent
• Sensory: Mild-to-moderate sensory loss, patient feels pinprick is less sharp or is dull on the affected side, or there is a loss of superficial pain with pinprick, but patient is aware of being touched
• Best Language: Mild-to-moderate aphasia (very mild, was able to repeat and name but missed few objects, limited description of the picture)
• Dysarthria: Normal
• Extinction and Inattention: No abnormality
• NIH Stroke Scale: 4

DDX

• Stroke
• Brain tumor
• Encephalitis 
• Hyperthyroidism 
• hypo/hyperglycemia 

Labs: As of 06/06/2023

ACTIVATED PTT – Abnormal

    Result Value

  Activated Partial Thromboplastin Time 38.5 (*)  

MAGNESIUM LEVEL – Abnormal

  Magnesium Level 2.5 (*)  

AUTO DIFFERENTIAL – Abnormal

  Neutrophil Automated 50.8  

  Lymphocyte Automated 35.60  

  Monocyte Automated 10.1 (*)  

  Eosinophil Automated 2.70  

  Basophil Automated 0.60  

  Imm Gran % 0.20  

  Absolute Neutrophil Count 2.68  

  Absolute Lymphocyte Count 1.87  

  Absolute Monocyte Count 0.53  

  Absolute Eosinophil Count 0.14  

  Absolute Basophil Count 0.03  

  Imm Gran Abs 0.01  

CBC W/ PLATELETS+ DIFF (COMPLETE)

  White Blood Cell 5.26  

  Red Blood Cell 5.15  

  Hemoglobin 15.3  

  Hematocrit 45.7  

  Mean Cell Volume 88.7  

  Mean Cell Hemoglobin 29.7  

  Mean Cell Hemoglobin Concentration 33.5  

  Red Cell Distribution Width 12.5  

  Platelet 234  

  Mean Platelet Volume 9.5  

  Nucleated RBC Auto 0.00  

  Absolute NRBC 0.00  

BASIC METABOLIC PANEL

  Sodium Level 140  

  Potassium Level 3.8  

  Chloride Level 104  

  Carbon Dioxide 26  

  Blood Urea Nitrogen 10.9  

  Creatinine 0.99  

  Glucose Level 76  

  Anion Gap 10  

  Calcium Level Total 9.5  

  BUN/Creatinine Ratio 11  

HEPATIC FUNCTION PANEL

  Protein Total 7.4  

  Albumin Level 4.9  

  Globulin 2.5  

  Bilirubin Total 0.4  

  Bilirubin Direct 0.1  

  Bilirubin Indirect 0.3  

  Aspartate Aminotransferase 23  

  Alanine Aminotransferase 22  

  Alkaline Phosphatase 100  

PROTHROMBIN TIME – INR

  Prothrombin Time 10.4  

  International Normalization Ratio 0.93  

TYPE AND SCREEN

  ABORh A Rh Positive  

THYROID EVALUATION (FT4,TSH)

  Thyroxine Free 1.23  

  Thyroid Stimulating Hormone 2.43  

PHOSPHORUS LEVEL

  Phosphorus Level 2.9  

ESTIMATED GLOMERULAR FILTRATION RATE

  Higher GFR estimate (approximate) >90  

  Lower GFR estimate (approximate) 82  

SARS-COV-2 NAAT

  SARS-CoV-2 NAAT Not Detected  

Stroke labs:

• Hemoglobin A1C: 6.3
• LDL Cholesterol,Direct: 120 (H)  
• Triglyceride:159.0
• Vitamin B12 Level: 423  
• Folate Level: 12.7  
• Homocysteine: 12

Imaging:

• XR Chest 1-View (AP Only) 06/06/2023 Impression: No evidence of acute disease. Thoracic aorta atherosclerosis.
• CT Head without IV Contrast 06/06/2023 Impression: No evidence of acute intracranial hemorrhage or large cortical based Infarct. Multiple old infarcts left the cerebral hemisphere, evolved from prior studies.
• CTA head and neck: Limited evaluation due to motion and positioning related to extensive streak artifacts. Minimal extracranial atherosclerotic changes likely due to multiple old infarcts. 
• EKG 06/06/2023: normal sinus rhythm, HR 70, PR interval <0.2 seconds, QTC interval <440 ms, no acute st segment changes.

Assessment:

60 y/o male with a history of HTN, HLD, current smoker, and stroke on 01/23 presents with dysarthria, slurred speech, and right upper extremity numbness for the past 3 days.Work up for stroke. HDS

Plan:

Dysarthria and numbness r/o stroke

• MRI brain without gadolinium
• Continue Plavix 75 MG Tablet, PO QD and aspirin 81 MG Tablet, PO QD.
• Continue atorvastatin 40 mg PO QHS
• Check Plavix assay and lipid profile daily. 
• Following review of the MRI, will consider brain SPECT without, then after 2 days brain SPECT with Diamox, in order to assess cerebrovascular reserve.
• Speech and swallow in house consult
• PT and OT consult
• Neurology consult
• Monitor patient on tele

HTN

• Target SBP 130-170, hold losartan unless over 170 

HLD

• Continue atorvastatin 40 MG Tablet, PO QHS

Smoking cessation

• Give patient nicotine patch 
• Consider bupropion if patient agrees

Other 

• Diet: cardiac diet
• Activity: Ambulate with assistance as needed 
• Disposition: admit the patient to the stroke unit for paresthesia, requiring further neurology follow up.
• Notify provider if:
  • Temp >38 or <36
  • SBP >180 or <90
  • HR >110 or <60 
  • RR >22 or <10 
  • SpO2 < 90
• Code: full
  • No advance directives on file: options discussed with patient and family 
  • Health care proxy on file is wife JS xxx-xxx-8421