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IM HPI

MEDICAL HISTORY                                                   Date:   7/7/21                        Time: 05:00am

IDENTIFICATION:   S.H.                                  

Sex:   M                  Race:  Bengali              Nationality: US           Age: 62     Marital status: Widowed

Address:     N/A                                  Religion: N/A

PCD: MD Rahman

Informant: self                                    Reliability: reliable                              Referral: Neurologist

CC: Dizziness

HPI

62-year-old male with a history of diabetes, HTN, HLD, cholecystectomy (2003), presenting to the ED complaining of dizziness, headache, blurred vision, and nausea. Patient states this has been going on for the last 7-8 years, worsening within the last 3 months. Patient report dizziness as constant, but worse with ambulation and describes it as “room spinning”. Patient also reports associated vomiting but none today and associated blurred vision during episodes, last episode being a “few days ago”. Was evaluated by neurologist 7/2/21 (MRA 6/20/21) and was referred to neurosurgery for severe 95-99% stenosis of the proximal LICA 0.9cm from the origin. As per pt son he was not able to get neurosurgery appointment, so he was sent to the ER by his PCD. At time of evaluation patient denies headache, nausea, vision changes, tinnitus, photophobia, unilateral weakness or paresthesias, nuchal rigidity, neck stiffness, denies slurred speech. Denies SOB or chest pain. Denies difficulty walking.

PMH:
Dizziness                              
Diabetes mellitus                      
Hypertension                            
LICA Carotid Stenosis 95-99%

PSH:
Cholecystectomy 2003

FH: Does not recall any pertinent family history

Social History:

S.H, is a retired 62 y/o widowed male living with his adult son and his family, independent in his ADLs and IADLs. Patient denies alcohol, caffeine or illicit substance use but states he has a history of 20 pack years smoking until he quit in 2017. States most of his meals are made by his son’s wife and he eats “traditional Indian food”. States he usually tolerates walking a few blocks before getting short of breath. Denies being sexually active.

Home Medications:


Alogliptin/Metformin 12.5/1000mg bid
Aspirin 81mg every day
Metoprolol 50mg every day
Senna + 52mg po every day
Omeprazole 40mg po every day
Amlodipine 10mg po every day
Folic Acid 1mg po every day
Repaglinide 2mg
Losartan 100mg po every day
Simvastatin 20mg qhs
Zolpidem Tartrate 5mg at bedtime

Allergies: No known allergies

ROS:

General: Denies any Fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Patient endorses intermitted headache and vertigo but not today, denies any head trauma, unconsciousness, coma, fracture

Eyes: Endorses intermittent blurry vision as per HPI; Denies use of contacts, glasses, fatigue, lacrimation, photophobia, pruritus

 Ears: Denies any deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses: Denies any discharge, epistaxis, obstruction

 Mouth and throat: Denies any bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam

Neck: Denies any localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Denies any dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Patient endorses history of HTN as per HPI; denies any chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system: Denies any changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Genitourinary: Denies any frequency, incontinence, dysuria, nocturia, urgency, oliguria, polyuria

Males: Denies any hesitancy, dribbling

Musculoskeletal system: Denies any muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular system: Denies any intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change

Hematologic System: Denies any anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine system: Denies any polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous system: Patient admits to dizziness as per HPI; denies any seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: Denies depression/sadness (Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder

Physical Exam

Vitals:

BP: 145/87, RA, supine

SpO2: 98% on room air

Resp: 21, unlabored      Pulse: 76 BPM

T: 36,9 C

H: 5.9        W: 168lbs       BMI: 24.8

General: A&O x 3, well developed, appears stated age, cooperative and in no distress

  • Skin: warm & moist, good turgor. Nonicteric, no tattoos.
  • Head: non-tender to palpation throughout; no ecchymoses no edema
  • Eyes: PERRL; symmetrical OU; no evidence of strabismus, exophthalmos, or ptosis; sclera white, conjunctiva & cornea clear.  
  • 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: No 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; no bruits noted bilaterally, no palpable adenopathy noted.
  • Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.
  • Chest: Symmetrical, no deformities, no evidence of trauma. 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 rate and rhythm; S1 and S1 with no murmurs or gallops. No splitting of S2 or friction rubs appreciated.
  • Abdomen: Soft, non-tender; 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 throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation
  • Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, No stasis changes or ulcerations noted. No 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. Full AROM in all joints.
  • Neuro: Normal finger-nose-finger. Normal heel-to-shin. No nystagmus. Patellar and triceps reflexes 2+ throughout; Plantar reflex present. Muscle strength 5/5 throughout. Gait: Narrow-based gait, arm swing intact. Able to tip-toe, heel-walk, tandem.
  • Cranial nerves: PERRL, no VF deficits, EOMI, no gaze preference or deviation, no nystagmus. Normal sensation in V1, V2, and V3 bilaterally. No facial asymmetry. Hearing intact to speech and finger rub bilaterally. Palate elevates symmetrically, uvula midline. 5/5 shoulder shrug bilaterally. Tongue midline

NIH Stroke Scale: 0

  • Psych: Normal mood and behavior

Pertinent Labs:

PT 11.8
INR 1.03
APTT 33.0

FS Glucose: 183 ; Hg A1C 8.3

Assessment:

62-year-old male with a history of diabetes, HTN, HLD, cholecystectomy (2003), presenting to the ED complaining of dizziness, headache, blurred vision, and nausea. Was evaluated by neurologist 7/2/21 (MRA 6/20/21) and was referred to neurosurgery for severe 95-99% stenosis of the proximal LICA 0.9cm from the origin.

PLAN:

1. Admit to stroke unit

2. In house CTA of the head and neck

3. MRI of the brain
4. Aspiration and fall precautions
5. DVT prophylaxis
6. Neuro checks q4 hrs
7. Fingerstick with insulin on sliding scale goal <150
8. Continue aspirin 81mg
9. Continue simvastatin 20mg at bedtime
10. Monitor BP
11. Tele while in house
12. Echocardiogram
13. Carotid doppler
14. Neurosurgery evaluation
15. Provide patient education on the reason for admission, etiology of his disease, importance of adherence with medication, and treatment options as well as alternative options and outcomes of no treatment at all

Neurosurgery Note:

CT Angiography revealed atherosclerotic plaque of the aortic arch, carotid bulbs, and skull
base/intracranial arteries.
 
Moderate focal stenosis of the proximal left ICA at the level of the carotid bulb.
 
Diffusely small caliber of the right cervical internal carotid artery.
Tapering of the petrous segment with occlusion of the cavernous and supraclinoid segments. Reconstitution at the carotid terminus.
 
Severe stenosis of the left cavernous/supraclinoid ICA with occlusion at the level of the terminus and the proximal left MCA M1 segment. Left MCA is supplied by prominent lenticulostriate collateral vessels. Findings are consistent with Moya Moya disease.

Moyamoya disease is a unique cerebrovascular entity characterized by progressive large intracranial artery narrowing and the development of prominent small vessel collaterals. The latter produces a characteristic smoky appearance on angiography, hence the name, “moyamoya,” a Japanese word meaning puffy, obscure, or hazy like a puff of smoke in the air.

  • Avoidance of hypotension, hypovolemia, hyperthermia, and hypocarbia.
  • Intravenous hydration with isotonic fluids at 1.25 to 1.5 times the normal maintenance rate is suggested
  • Some experts keep blood pressure slightly elevated
  • Supplement O2
  • Unfortunately, there is no acute intervention that is known to improve stroke outcome in patients with moyamoya. The use of thrombolytic therapy or antithrombotic agents during the acute phase of ischemic stroke associated with moyamoya disease has not been studied in any systematic way.
  • Because of the risk of hemorrhage in areas of extensive moyamoya collateral vessels, many experts are reluctant to use thrombolytic therapy to treat acute ischemic stroke in patients with moyamoya 
  • Revascularization

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