DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Stroke.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presented with new onset of left-sided weakness. Evidently, this morning, the patient was found down on the floor. He was diaphoretic and vomiting. The patient cannot remember exactly what time the symptoms started but did note that last night is when his left-sided weakness started because when he tried to stand up, he could not, because of his left leg. The patient does have a history of diabetes, hypertension and hyperlipidemia. No previous history of stroke. The patient states that his blood pressure has been under good control recently. The patient does check his blood sugars and they have been in the 200 range. The patient has also been significantly dysarthric. He has had increasing respiratory symptoms as well since his admission. He does feel that he has been choking on his food, since his symptoms started. The patient was admitted to CICU with elevated troponin levels, white count, procalcitonin and fever. Urinalysis was positive. Also, he was found to be acidotic. CT of his head this morning in the emergency department showed no acute intracranial abnormality. MRI of the brain done this morning showed right frontal stroke.
REVIEW OF SYSTEMS:
Ten point review of systems completed and negative, except for what was noted in history of present illness.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Hypertension.
3. Hyperlipidemia.
CURRENT MEDICATIONS:
1. Cefepime 1 g IV every 12 hours.
2. Aspirin 325 mg daily.
3. Sliding scale insulin.
4. Heparin 5000 units subcutaneous every 8 hours for DVT prophylaxis.
5. Metoprolol 25 mg p.o. daily.
6. Pravachol 20 mg p.o. daily.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
The patient is married. No history of tobacco or alcohol use.
FAMILY HISTORY:
Brother and sister have had strokes. Both parents had heart disease.
VITAL SIGNS: Heart rate 100, blood pressure 192/100, oxygen saturation 98% on 2 liters.
GENERAL: A pleasant male who is lying in the bed, in no acute distress. He does, however, appears slightly anxious.
HEENT: The patient has mild left facial droop. Visual fields are intact. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are full and conjugate.
HEART: The patient has 2+ systolic murmur. Regular rate and rhythm.
LUNGS: No coarse lung sounds and wheezes, otherwise diminished throughout.
ABDOMEN: Soft, nontender and nondistended.
EXTREMITIES: The patient has bilateral lower extremity edema.
NEUROLOGIC: The patient is awake, alert and oriented x3. Speech is moderately dysarthric. The patient follows simple commands. Cranial Nerves: Pupils equal, round and reactive to light and accommodation. Extraocular movements are full and conjugate. Visual fields are intact. The patient has left facial droop, decreased sensation in the left base. Tongue and uvula are midline. Positive corneal reflex. Motor: The patient moves the right upper extremity. Full strength is 5/5. Right lower extremity is generally weak, but able to lift in antigravity. The affected side is the left side. Left upper extremity strength is 3/5 and left lower extremity is 1/5. Sensation is decreased on the left. Coordination: No limb ataxia noted.
LABORATORY DATA: White blood cell count 22.6, hemoglobin 8.6, hematocrit 27.4 and platelets 224,000. Sodium 141, potassium 4.2, BUN 44, creatinine 0.8, glucose 212. AST 24, ALT 16, alkaline phosphatase 98. GFR 35, calcium 8.1, amylase 156, lipase 36, lactic acid 2.2, procalcitonin 1.2. Cortisol 63.6. Troponin T is 0.44. D-dimer 4388. Urinalysis this morning showed positive nitrites, rbc’s, wbc’s bacteria and protein. CT of the head this morning showed no acute intracranial abnormality. Chest x-ray showed diffuse infiltrate/edema. MRI of head showed acute/subacute infarct, medial right frontal lobe. V/Q scan was normal. Bilateral lower extremity venous Dopplers were negative for deep venous thrombosis.
IMPRESSION:
1. Right frontal lobe stroke.
2. Possible Dysphagia
3. History of hypertension.
4. History of diabetes mellitus, poorly controlled recently.
5. Hyperlipidemia.
6. Elevated troponin.
7. Urinary tract infection.
8. Acute renal insufficiency.
PLAN: We will place the patient on a stroke pathway. We will get frequent NIH stroke scale and monitor neurologic status closely. We will check a MRA of head and neck to rule out large vessel occlusion. We will check a fasting lipid panel and hemoglobin A1c. We will consult physical therapy, occupational therapy and speech therapy.
Thank you, Dr. Doe, for allowing us to participate in the care of this pleasant patient.
