3/3/06 Case

1. 3/3/06 Case

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

3. What questions do we want to ask this patient?

4. History of Present Illness • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment 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.

5. 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

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

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

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

9. 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

10. 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

11. 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

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

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

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

15. CBC • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment 13.9 g/dl 10.6 139 41.5 Chemistry 14 137 103 155 4.0 27 1.7

16. 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 pneumoniaEKG NSRCT Brain No bleed, infarct or mass shift

17. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Diagnosis • Pt is a 55 year old caucasion male with right-sided weakness, starting today and improving, most likely TIA but must r/o CVIOn ASAWill add Plavix 75mg dailyCounseled patient about smoking cessationLipid panel • GerdZantac 150mg bid

18. Thank you! • Questions, comments, concerns?