Nice job on this. Good capture of information, sequencing and particularly good pursuit of the specifics on PE relevant to the chief concerns. Could use a little more exploration of the fall and note my comments on the assessment and imaging information how it might be placed/discussed differently
MEDICAL HISTORY #1 Date: 05/11/21 Time: 11:00
Sex: M Race: Indian Nationality: US Age: 69 Marital status: Married
Address: N/A Religion: N/A
PCD: Dr.Bhangoo, MD
Informant : self Reliability: reliable Referral: none
A 69 y/o M w a medical Hx of being an active smoker, COPD, uncontrolled DM, HTN and alcohol use disorder is admitted after presenting to ER yesterday with a c/o progressive Left Upper and Lower extremity weakness x 4 days. Patient was also admitted to ER 7 days ago after a fall. The fall happened in a setting on patient tripping on the stairs after drinking a pint of vodka. De denied any LOC, incontinence, tongue biting or post ictal state. His wife witnessed the fall and called 911. As discussed, need a little more about the fall if it’s possible (or state that it is not obtainable and why) – fell onto what surface, hitting what body parts, with/without LOC, complaints afterward, etc. Wife stated he drinks every day but has not fallen in the past 3 years. In ER after the fall 7 days ago a Head CT was negative, chest X-ray, X-ray of the L ankle, foot and knees were also negative for fractures. Patient was discharged then but he states on Saturday (4 days ago) he had an onset of left upper and lower extremity weakness without resolution and decided to go to ED when the weakness impaired his balance and he could no longer walk. (baseline status – able to ambulate on his own). On admission, patient denies any facial droop, slurred speech, difficulty swallowing, changes in vision or sensation impairment. Denies any dizziness, chest pain, palpitations, or shortness of breath at this time. Denies any fever, chills, abdominal pain, nausea or vomiting.
- Alcohol abuse
- Vaccination status unknown
- Losartan 50 mg (Cozaar) tablet – non-compliant
- Fluticasone-Umeclidin-Villant (Trellegy Ellipta In) inhaler – uses daily
- Tamsulosin (Flomax) 0.4 mg capsule – takes daily
- Father: deceased at 78, cause unknown
- Mother: deceased at 65, “Heart disease”
- Siblings: alive & well
O.H. is a retired salesman who lives with his wife in a basement apartment with 12 steps to enter. Before the onset of his symptoms he was independent in ADLs and functional mobility. Admits to drinking a pint of vodka daily, last drink last Monday (8 days ago). Denies ever going into withdrawal or being admitted for intoxication. Patient states he is not sexually active at this time. States he spends most of his time at home drinking and does not exercise. According to the patient, his wife cooks traditional Indian food but he does not usually have much appetite. Denies any illicit drug use
Allergies: NKDA NKEA NKFA
Review of Systems:
General: Endorses diminished appetite since when, any associated weight loss?(or change in clothing fit/size); denies any fever, chills, night sweats, fatigue
Skin, hair, nails: Denies any changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
Head: Denies any headache, denies vertigo, unconsciousness, coma
Eyes: Denies photophobia , Denies visual disturbances, fatigue, lacrimation
Ears: Denies deafness, pain, discharge, tinnitus
Nose/Sinuses: Denies discharge, epistaxis, obstruction
Mouth and throat: Denies bleeding gums, sore tongue, difficulty swallowing
Neck: Denies localized swelling/lumps, stiffness/decreased range of motion
Pulmonary system: Endorses occasional cough and dyspnea but none today; denies SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND
Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur
Gastrointestinal system: Denies nausea, vomiting, denies changes in appetite, intolerance to foods, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank
Genitourinary: Endorses occasional hesitancy & dribbling but none today; denies frequency, incontinence, dysuria, nocturia, urgency, oliguria, polyuria
Musculoskeletal system: Endorses occasional bilateral knee joint pain but none today; denies deformity, swelling, arthritis
Peripheral Vascular system: denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change
Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE
Endocrine system: Endorses occasional polydipsia; denies generalized weakness, polyuria, polyphagia, heat or cold intolerance, goiter, hirsutism
Nervous system: Endorses loss of strength in left upper and lower extremity as per HPI; denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, change in cognition/mental status/memory
Psychiatric: Denies depression/sadness (Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder
General: Patient is alert and oriented x 3, well developed well nourished, cooperative and in no acute distress
- BP: 159/104 RA Supine
- Pulse: 67 BPM
- Resp: 18 r/min, unlabored
- T: 98.1F, oral
- SPO2: 98% RA
- H: 5.4
- W: 134lb
- BMI: 23.0
- Skin: warm & moist, good turgor. Nonicteric, no tattoos.
- Head: abrasion present of left pterion perhaps you mean “over the left pterion”? (can’t really tell if the skull itself is bruised on inspection); no ecchymoses no edema
- Eyes: PERRL; symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera injected in both eyes, conjunctiva & cornea clear. Lens opacification?
- Ears: Symmetrical and normal size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU.
- Nose and sinuses: Symmetrical / no masses / lesions / deformities / trauma / discharge. Septum midline
- Throat: do gross deformities noted in mouth, dentition and oropharynx. Throat non-injected, no exudates, uvula midline.
- Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.
- Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
- Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored; no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.
- Lungs: Chest expansion symmetrical. Clear to auscultation bilaterally. No adventitious sounds.
- Heart: Regular S1 and S1 with no murmurs or gallops. No splitting of S2 or friction rubs appreciated.
- Abdomen: flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation would be important to pay particular attention to liver size and texture in this patient – liver span should be indicated specifically (why?)
- Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper extremities except LLE DP pulse 1+, RLE DP pulse 2+. As discussed, would want to note PT pulses in the presence of a diminished DP pulse since posterior tibialis A is the bigger supplier. No bruits noted. No clubbing, No stasis changes or ulcerations noted. No pitting edema. Homan’s sign negative.
- MSK:No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. No evidence of spinal deformities.
ROM: Passive ROM vs. Active ROM important to establish here
Hands and Wrists: Right FROM; Left: limited due to weakness and hypotonicity
Elbows: Right: FROM: Left: limited due to weakness and hypotonicity
Shoulders: Right: FROM: Left: limited due to weakness and hypotonicity
Ankles and Feet: Right: FROM: Left: limited due to weakness and hypotonicity
Knees: Right: FROM; Left: limited due to weakness and hypotonicity
Hips: Right: FROM; Left: limited due to weakness and hypotonicity
- Neuro: Alert. Normal speech, normal tone. Unable to access gait due to patient being unable to walk. Patient is able to sit himself upright and to lay back down without assistance. CN II – XII intact.
- Muscle strength: Great work on documenting specifics here
- Muscle strength: Great work on documenting specifics here
- Shoulder flexion, external rotation, internal rotation, abduction, adduction ← 2/5 (gravity eliminated)
- Elbow flexion, extension, supination, pronation ← 3/5 (+gravity – resistance)
- Wrist: flexion of wrist ← 3/5; extension of wrist ← 2/5
~ Flex w resistance extend w/o resistence
- Hand: Finger flexion ←3/5; extension ← 2/5
- RUE: 4/5 throughout
- RLE: 4/5 throughout
- 4/5 on hip flexion, extension, internal/external rotation, abduction/adduction
- 3/5 on knee flexion, internal/external rotation
- 3/5 Ankle inversion, eversion, dorsiflexion, plantarflexion
- Often test great toe dorsiflexion/plantar flexion as well in this context
- RUE: 4/5 throughout
- Sensation intact throughout. In the context of a CVA, want to note sensation to what – sharp/dull, light touch, vibration
- Pronator drift and Asterixis are grossly negative but hard to appreciate because of hemiparesis Should Asterixis still be elicited on R if present? What is the cause of asterixis – would it be affected on both sides? Pronator drift is a more subtle sign, used to detect a smaller stroke. Here the bigger finding of hemiparesis makes the search for subtler signs not as important.
- Normal finger-nose-finger, although limited to right arm only. Heel-to-shin is the equivalent in the LE
- Proprioception intact Here I would note how tested – e.g. proprioception great toe intact bilaterally (or only on the R)
- No nystagmus.
- Patellar and triceps reflexes 2+ throughout Other important DTRs here would be biceps, brachioradialis, and ankle jerks (likely to be different on L and R)
- Plantar reflex present usually say whether it’s normal or not rather than present.
- FS: 118
- BUN/Cr: 19/1.41
- GFR: 54
- Hg: 13.5
- Platelets: 148
- Mg: 1.4
- Covid-19: negative
Assessment and Plan
Pt is a 69 y/o m who has a PMH of EtOH abuse, BPH, COPD, DM2 and HTN, presents with weakness, impaired ROM, coordination, and endurance on LUE and LLE due to hemiparesis. As a result, has difficulty performing ADL tasks of dressing, bathing, and toileting along with functional mobility. Upon assessment, pt was A&O x 3 and cooperative. He was able to follow commands w/o difficulty and perform functional movements. No facial drooping, dysarthria, or dysphagia present. Sensation and proprioception were intact. RUE was within normal limits and MS was grossly 4/5, with good grip strength. LUE ROM was limited due to weakness and hypotonicity. Pt is able to show isolated volitional movements of left shoulder (2/5), elbow (3/5) and wrist (3/5 and 2/5). Pt was unable to raise left arm and demonstrated weak grasp strength of left hand. LLE ROM also limited. Isolated volitional movements of left hip (4/5), knee (3/5) and ankle (3/5) were noted although the LLE is non-weight bearing at this time. Pt has good static/dynamic sitting balance with poor standing balance. RLE grossly within normal limits with muscle strength 4/5 and a full ROM. Good summary
- Head CT to r/o hemorrhage ← negative
- Head MRI ← acute to subacute infarct of posterolateral right basal ganglia/thalamocapsular area including corona radiata corresponding to the area of low attenuation seen on the CT exam. Would usually include these with the lab data above and then perhaps refer to them in your summary – e.g. “MRI findings indicate infarct R posterolateral basal ganglia/thalamocapsular area”
- Manage BP but allow for permissive hypertension (see HTN)
- EKG to look for any cardiac pathology (especially A-Fib)
- TTE – look for vegetations and valvular disease
- Cardiac monitor
- CBC, CMP, AlkPhos, CK-MB, lactic acid
- ASA 325mg; Lipitor 80mg daily
- L Lower extremity duplex
- Neck MRA
- Speech and swallow consult
- Neuro consult
- Physical Therapy/OT consult
- Fall precautions, Education on fall prevention strategies
- HTN ← allow for permissive hypertension of 165-195/85-105 for up to 24 hrs
- Alcohol use disorder
- CIWA Protocol
- Ativan as per CIWA
- Monitor CBC, BMP, Mg, Phos
- Folic Acid, thiamine, B12
- DVT Prophylaxis: Lovenox 40mg subcutaneous
- COPD ← not active at this time; continue current regimen.
- BPH ← not active at this time; continue current regimen.
- DM2 ← FS glucose of 118 does not warrant an intervention at this time. Arrange a follow up with the PCP
- Smoking ← counseling on dangers of smoking, offering resources to help with quitting, arrange PCP follow up.
- From a geriatric medicine point of view, there might also need to be some discussion of the mobility issues – what will he need in terms of rehab, supportive devices, Home Aid hours etc. This can be general for now since not assessed by PT/OT yet, but to introduce it as a category on the problem list helps focus attention in a more holistic way
- Alcohol use disorder
Just a suggestion (which you are free to disagree with) – might use the phrase “stable” or ‘well controlled” rather than “not active” since he still has DM, COPD, BPH.