Unspecified transient cerebral ischemia Unspecified essential hypertension Other and unspecified hyperlipidemia Tobacco use disorder Other specified counseling
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROLOGY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
slurred speech
 
Major Surgical or Invasive Procedure:
N/A

 
History of Present Illness:
History of Present Illness (per Dr. ___:

The pt is a ___ Left handed woman who presents as a
code stroke. She was in normal state of health when at 10 pm she
suddenly developed acute onset of slurred speech. Along with 
this
she states that she felt as though her whole left side of her
body felt week from her arm to foot. These symptoms lasted about
___ min and resolved on there own except she still thinks her
left arm is weak. This was witnessed by a friend who notified
family first. 

At the time of eval her only symptoms were residual left side
weakness feeling and just like it does not move in the right 
way.
otherwise no sensory symptoms no vision symptoms. She normally
drinks a "small" bottle of wine per day and today had 4 glasses
of wine but not a full bottle. She denies ever suffering from
withdraw symptoms. She smokes a pack a day and she states she 
has
HLD and HTN but does not take meds for this.

 
Past Medical History:
Hypertension
Hyperlipidemia
Tobacco use
 
Social History:
___
Family History:
Her father had a history of MI in his ___.
 
Physical Exam:
Physical Exam (on arrival to hospital on ___:

Vitals: T:98  P:70  R: 16  BP: 129/54 SaO2:98
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally. Barrel chest
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No edema  bilaterally, 2+ DP pulses bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Attentive, able to name ___ backward 
without
difficulty.  Language is fluent with intact repetition and
comprehension.  There were no semantic or phenomic paraphasic
errors.  Able to read without difficulty.  Speech was mildly
dysarthric.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation. 
III, IV, VI: EOMI with 5 beat nystagmus at b/l lateral gaze.
V: Facial sensation intact to light touch.
VII: left facial to smile.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No tremor, asterixis noted.
Strength was 5+ on the right and 5 on the left. there was give
way component.

There was some slow movements to RAM and Fine finger movements 
on
the Left  

-Sensory: No deficits to light touch, extinction to DSS.

-DTRs:
  Bi Tri ___ Pat Ach
L  2  2    2    1   0
R  2  2    2    1   0
Plantar response was flexor bilaterally.

-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. Slightly slower with 
left
FNF testing

-Gait: not tested

 
Pertinent Results:
LABS:
___ 07:58AM   CK(CPK)-150
___ 07:58AM   CK-MB-3 cTropnT-<0.01
___ 07:58AM   CHOLEST-214*
___ 07:58AM   TRIGLYCER-110 HDL CHOL-56 CHOL/HDL-3.8 
LDL(CALC)-136*
___ 07:58AM   TSH-2.4
___ 03:00AM URINE  TYPE-RANDOM COLOR-Straw APPEAR-Clear SP 
___
___ 03:00AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-NEG
___ 01:06AM   GLUCOSE-104* UREA N-8 CREAT-0.7 SODIUM-142 
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-27 ANION GAP-14
___ 01:06AM   estGFR-Using this
___ 01:06AM   cTropnT-<0.01
___ 01:06AM   CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-2.3
___ 01:06AM   ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG 
barbitrt-NEG tricyclic-NEG
___ 01:06AM   WBC-9.9 RBC-4.40 HGB-14.7 HCT-41.2 MCV-94 
MCH-33.4* MCHC-35.7* RDW-12.8
___ 01:06AM   NEUTS-55.5 ___ MONOS-5.3 EOS-4.9* 
BASOS-0.9
___ 01:06AM   PLT ___ 01:06AM   ___ 
PTT-27.9 ___

IMAGING:
MRI w/o contrast      Date: ___
FINDINGS: There is no evidence of acute infarct seen. There is 
no mass 
effect, midline shift or hydrocephalus identified. There are no 
significant focal abnormalities. Small areas of hyperintensity 
in both atrial regions of the ventricles on diffusion images are 
due to incidental small choroid plexus cysts. The suprasellar 
and craniocervical regions are unremarkable. The vascular flow 
voids are maintained. 
IMPRESSION: No significant abnormalities on MRI of the brain 
without 
gadolinium. No acute infarcts. 

CTA neck and head      Date: ___
CTA HEAD: CTA of the head demonstrates normal vascular 
structures in the 
anterior and posterior circulation without stenosis, occlusion 
or an aneurysm greater than 3 mm in size. 
  
IMPRESSION: 
1. No significant abnormality on CT head without contrast. 
2. CT angiography of the neck demonstrates mild-to-moderate 
atherosclerotic 
disease at the left carotid bifurcation with less than 50% 
narrowing and 
calcified plaque. 
3. No significant abnormalities on CT angiography of the head. 

ECHO                  Date: ___
IMPRESSION: 

 
Brief Hospital Course:
Ms. ___ was admitted to the hospital on ___ with a chief 
complaint of slurred speech and left-sided numbness and weakness 
in her upper and lower extremities. On HD1, the patient was 
evaluated by the stroke felow who completed a full exam prior to 
any neurological imaging. She had a head CT without contrast 
that was negative for acute process based on the preliminarty 
read. She was admitted to the neurology service to rule stroke. 
She was initially ruled out for MI with serial tropinins. 
She received one dose of aspirin 325mg in the emergency 
department and this dose was decreased to ASA 81mg when she was 
transferred to an inpatient floor. 

A lipid panel was ordered and the patient was started on a 
statin. Her blood pressure was maintained between 140 and 180. 
She received smoking cessation counseling and was started on a 
nicotine patch. We also encouraged the patient to decrease her 
alcohol intake because it increases her risk of stroke. She was 
started on thiamine and folate due to her recent alcohol use. 
On HD2, the patient received an ECHO that was equivocal for 
showing a PFO. A TEE was recommended but not done. She was also 
discharged with a nicotine patch.

 
Medications on Admission:
None
 
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 2 weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr 
Transdermal DAILY (Daily) for 2 weeks.
Disp:*14 Patch 24 hr(s)* Refills:*1*
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) 
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily) 
for 2 weeks. Tablet(s) 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis: 
Transient ischemic attack (TIA)
Dyslipidemia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Ms. ___, 

    It was a pleasure taking care of you during your hospital 
admission. You were admitted after you developed left side 
numbness and slurred speech. During your admission, we completed 
a head CT and MRI scan that revealed no significant 
abnormalities. However, based on your clinical examination, we 
suspect that you had a transient episode with decreased blood 
flow to your brain. The neurologic deficits improved during your 
hospital stay. We encourage smoking and alcohol cessation to 
decrease your risk of stroke. 

Please follow up in 6 to 8 weeks with Dr. ___ 
discharge. His office phone number is as follows: 
___.
 
Followup Instructions:
___

{'slurred speech': ['Unspecified transient cerebral ischemia'], 'left side numbness': ['Unspecified transient cerebral ischemia'], 'left side weakness': ['Unspecified transient cerebral ischemia'], 'history of hypertension': [' Unspecified essential hypertension'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'tobacco use': ['Tobacco use disorder'], 'alcohol use': ['Other specified counseling']}