Syncope and collapse Unspecified visual disturbance Tinnitus unspecified ear Essential (primary) hypertension Hemorrhage of anus and rectum Aneurysm of carotid artery Psoriasis unspecified Gastro-esophageal reflux disease without esophagitis Orthostatic hypotension
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Syncope, Visual Changes, Tinnitus
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
___ yo M ___ M with history of ?TIA, HTN, HLD, who
presents with episodes of altered consciousness.

Occurred ___ in the morning while sitting, he describes
feeling out-of-body in that his perception was "off," and then
his vision in both eyes narrowed circumferentially and then
expanded. He sat down in a chair, and continued to have series 
of
about 6 brief episodes of this. He then loses memory of what
happened. Per sister, her other brother witnessed this and 
stated
he was not speaking but remained sitting up without fall or
convulsions, loss of bowel or bladder function. Directly prior 
to
these episodes he could hear a "whooshing sound" in his ear. He
recovered quickly from the events without any weakness numbness
or balance issues. He does say his chest felt "tight" prior to
the episodes. He did have palpitations, lightheadedness, chest
pain, shortness of breath.

He reports they also occurred about 4 months ago, and again 6 
months prior to that.  They did occur in the setting of poor PO 
intake and possibly taking an extra dose of his Amlodipine.  
There was no clear positional component to his symptoms.

He denies melena, hematochezia. He does have a history of
"ulcers" diagnosed 6 weeks ago in ___. He had an EGD there. He
does not recall being told if he had H. pylori. He was put on
several medications, he believes antibiotics for a total of 3
weeks to which he was compliant. also reports he intermittently
notices blood on his toilet paper and that a lump extrudes at
times when he strains when having bowel movements.

He recently moved to ___ from ___ within the last two weeks.
He is living with his sister. He used to drink heavily but has
not had alcohol in "many years." He denies other drug use.

He denies fevers, chills, nausea, diaphoresis, any recent cough,
abdominal pain, shortness of breath. He denies dyspnea on
exertion.  

In the ED, initial VS were: 98.1 67 115/70 19 100% RA 

Imaging showed: 
NCTH with no acute intracranial abnormality
CXR wnl

Neuro were consulted and recommended to admit to medicine for 
syncopal/cardiac
work-up

On arrival to the floor, patient reports he is feeling well. He
is concerned that he had a small amount of blood on the toilet
paper when having a bowel movement upon arrvial. He is very
worried about this. He does strain when having bowel movements.
 
Past Medical History:
? PUD
Psoriasis
HTN
HLD
? TIA
? CAD
? "arrhythmia"
 
Social History:
___
Family History:
mother- uterine cancer
father- kidney cancer
maternal grandmother kidney cancer
no family history of strokes or seizure
 
Physical Exam:
EXAM ON ADMISSION
======================
tele sinus, rates ___
VS:  96.4 AdultAxillary 91 / 58 60 18 94 Ra 
GENERAL: NAD, laying comfortably in bed. barrel-chested
HEENT: AT/NC, EOMI, PERRL,pink conjunctiva, MMM
NECK: no JVD  
HEART: Distant heart sounds, RRR, S1/S2, no murmurs, gallops, or
rubs  
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles  
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly  
Rectal: deferred per patient
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally  
NEURO: A&Ox3, CNII-XII, strength, sensation grossly intact 
SKIN: warm and well perfused, no excoriations. hyperpigmented
patches to back.  

EXAM ON DISCHARGE
===========================
Vitals:  98.0, 130/76, hr 64, RR 17, 97 Ra 
Telemetry:  sinus with rates 50-60's
General: Alert, oriented, no acute distress, well appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, no LAD  
Lungs: normal WOB on room air
CV: RRR, no murmur, no gallop
Abdomen: soft, NT/ND
Ext: warm, no edema
Neuro:  Moving all extremities. Able to walk the halls with a 
normal gait.
Skin:  No rash or lesion
 
Pertinent Results:
ADMISSION LABS
=========================
___ 03:14PM BLOOD WBC-6.3 RBC-4.38* Hgb-13.2* Hct-39.8* 
MCV-91 MCH-30.1 MCHC-33.2 RDW-12.3 RDWSD-40.7 Plt ___
___ 03:14PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-142 
K-4.2 Cl-106 HCO3-20* AnGap-16
___ 04:28PM BLOOD ___ PTT-31.1 ___
___ 03:14PM BLOOD cTropnT-<0.01
___ 05:28AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:14PM BLOOD CK(CPK)-102
___ 05:28AM BLOOD ALT-27 AST-21 AlkPhos-96 TotBili-0.6
___ 05:28AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.3
___ 03:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG 
Barbitr-NEG Tricycl-NEG
___ 04:34PM BLOOD Lactate-0.8
___ 04:45PM URINE Blood-TR* Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG 
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG

DISCHARGE LABS
===========================
___ 05:12AM BLOOD WBC-5.5 RBC-4.40* Hgb-13.2* Hct-40.8 
MCV-93 MCH-30.0 MCHC-32.4 RDW-12.3 RDWSD-42.5 Plt ___
___ 05:12AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-140 
K-4.6 Cl-103 HCO3-27 AnGap-10
___ 05:12AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3 Iron-115

MICROBIOLOGY
===========================
___ 4:45 pm URINE
   URINE CULTURE (Preliminary): 
      GRAM POSITIVE BACTERIA.    10,000-100,000 CFU/mL

REPORTS
===========================
CTA Head and Neck ___
Right MCA aneurysm measuring 5 x 4 x 3 mm. The aneurysm has a 
slightly 
lobulated/irregular appearance.
No significant ICA stenosis by NASCET criteria. 
There is poor opacification of the left vertebral artery at its 
origin, this may be secondary to its tortuous origin or be 
related stenosis. Rest of the vertebral arteries and basilar 
artery are widely patent with no significant stenosis. 
Lobular/tubular structure just posterior to the suprasternal 
notch which seems to connect to the left brachiocephalic vein 
which most likely represents an anomalous venous structure. 
However correlation with neck ultrasound is advised. 

NCCT Head ___
No acute intracranial abnormality.

CXR ___
No acute cardiopulmonary abnormality. 

EEG ___
This is a normal awake and asleep EEG with no epileptiform 
discharges or features.

EKG ___
Sinus Bradycardia
 
Brief Hospital Course:
___ from ___, reported hx of possible CAD, possible hx of TIA, 
possible hx of "arrhythmia," HTN, HLD, who presented to the ED 
with transient episode of alteration in consciousness, visual 
changes, and tinnitus.

He reports episodes of symptoms similar to this occurring about 
6 months ago, and again a few months before that, while in ___. 
No etiology had previously been identified.

On arrival to the floor, orhostatics were positive. He received 
IV fluid and Amlodipine was stopped. Even after stopping 
Amlodipine, blood pressures remained low-normal, so it was 
discontinued.

He had a workup for this while in house, including telemetry 
monitoring (no tachy- or bradyarrthymia was seen), CT of the 
Head, EEG, and EKG, all of which were normal or unremarkable. 
Neurology was consulted in the Emergency Room, and recommended a 
CTA of the Head and Neck. This was negative for acute pathology 
in the posterior circulation to explain his presenting symptoms, 
but did show an incidental Right MCA aneurysm measuring 5 x 4 x 
3 mm.

He had no further symptoms or episodes while in house, and was 
feeling well on the day of discharge. Ultimately, given the lack 
of other etiology identified, his symptoms were felt to most 
likely be due to orthostatic hypotension in the setting of 
Amlodipine, but he will need further monitoring as an outpatient 
for recurrence of symptoms and consideration of further workup.

CHRONIC ISSUES
========================
# HLD - Atorva 20mg daily
# HTN - holding amlodipine given hypotension and positive 
orthostatics, as above
# CAD (per report) - Aspirin 81mg
# GERD - omeprazole 40mg daily

TRANSITIONAL ISSUES
========================
[ ] NO HEALTH INSURANCE at the time of discharge. Patient is 
having ongoing discussions with the Financial Department at 
___ for arranging insurance. Once insurance arranged, he will 
be contacted by ___ Health Care Associates and see Dr. ___ 
___ in clinic
[ ] have STOPPED Amlodipine given orthostatic hypotension on 
admission and normal BP's without it
[ ] incidental Right MCA aneurysm measuring 5x4x3mm found on CTA 
of Head and Neck
[ ] mild normocytic anemia with normal iron studies, B12, 
Folate. Follow up as outpatient.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM 
2. Aspirin 81 mg PO DAILY 
3. amLODIPine 5 mg PO DAILY 
4. Omeprazole 40 mg PO DAILY 

 
Discharge Medications:
1.  Aspirin 81 mg PO DAILY  
2.  Atorvastatin 20 mg PO QPM  
3.  Omeprazole 40 mg PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Syncope - likely from antihypertensive medication
Incidental finding of R MCA Aneurysm
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
Mr. ___,

It was a pleasure meeting you at ___.  You were admitted to 
our hospital after developing dizziness, passing out, visual 
symptoms, and ear ringing.  We did multiple tests.

We found that your blood pressure was low, and for this we gave 
you IV fluids and stopped your Amlodipine.

The EEG of the brain did not show any seizures.  Your Head CT 
did not show anything to explain your symptoms.  It did show a 
finding of an aneurysm in one of the arteries of your brain.  
This was NOT what was causing your symptoms, but you will need 
to follow up on this as an outpatient to for further monitoring.

Please stop your Amlodipine, and continue your other 
medications.

It was a pleasure, we wish you the best,
___ Medicine Team
 
Followup Instructions:
___

{'Syncope': ['Syncope and collapse'], 'Visual Changes': ['Unspecified visual disturbance'], 'Tinnitus': ['Tinnitus', 'unspecified ear'], 'Altered Consciousness': ['Syncope and collapse'], 'Chest Pain': [], 'Palpitations': [], 'Lightheadedness': [], 'Shortness of Breath': [], 'Tightness in Chest': [], 'Whooshing Sound': ['Tinnitus'], 'Memory Loss': [], 'Narrowing of Vision': ['Unspecified visual disturbance'], 'Expansion of Vision': ['Unspecified visual disturbance'], 'Out-of-body Perception': [], 'Loss of Bowel or Bladder Function': [], 'Convulsions': [], 'Fall': [], 'Ulcers': ['Gastro-esophageal reflux disease without esophagitis'], 'Blood on Toilet Paper': ['Hemorrhage of anus and rectum'], 'Lump Extrudes': [], 'Straining with Bowel Movements': [], 'History of TIA': ['Essential (primary) hypertension'], 'HTN': ['Essential (primary) hypertension'], 'HLD': ['Essential (primary) hypertension'], 'CAD': ['Essential (primary) hypertension'], 'Arrhythmia': [], 'Right MCA Aneurysm': ['Aneurysm of carotid artery'], 'Psoriasis': ['Psoriasis', 'unspecified'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Orthostatic Hypotension': ['Orthostatic hypotension']}