3/3/06 Case.


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3/3/06 Case . Boss Complaint. Pt is a 55 y/o caucasion male who presents with right-sided shortcoming that began the previous evening. What inquiries would we like to ask this patient?. History of Present Illness. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS
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3/3/06 Case

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Chief Complaint Pt is a 55 y/o caucasion male who presents with right-sided shortcoming that began the previous evening.

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What questions would we like to ask this patient?

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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 shortcoming. He expresses this started after awakening at around 1:30 am. He saw that he was not able keep up parity and was confused and was slurring his words. He saw that something was distinctive and went to the crisis room. This happened some time recently, around 5-6 years prior, yet just endured around 20 minutes. He states he started feeling better around 4-5 am. At first he experienced difficulty gulping however this has subsequent to determined. Amid the scene he denied any mid-section torment, palpitations, wooziness or vertigo. He notes that he drank 5-6 brews, which is surprising for him. He likewise denies seizure, gut or bladder incontinence or lip cuts.

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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

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

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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Allergies Residents who ask an excessive number of inquiries

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

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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Family Medical History Paternal grandma had a CVI at 60

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Review of frameworks General: weight change, fever, chills, powerless, slurring words Head: migraine, nasuea, vomitting Respiratory: SOB, wheeze, no hack or URI Cardiac: HTN, mumbles, hx angina, palpitations GI: craving, n/v, incont., no const/looseness of the bowels, frequency, reluctance, criticalness, dysuria hematuria, incont., stones, no dyspareunia, no release MSK: muscle shortcoming , flank torment, muscle cramps, right sided shortcoming not involving face Neuro: parasthesias, loss of sensation Psychiatric- Pt is not restless or discouraged CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment

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Physical Exam VS- BP-160/94 HR 91 R 18 T 98 Pulse bull 95% General-Pt is all around sustained and AxOx3 Heent- EOMI, PERRLA, no vision changes, no tongue deviation, no sensation misfortune on face CV- RRR w/o mumbles or rubs, snaps or dashes RESP- Clear to auscultation respectively, no wheezes, rales or crackles Abdomen-Soft, NT, no bounce back, ND, no masses GU- No release, draining MSK- 4/5 MMT on R UE and LE, no stride aggravations TTA T5-8 on left EXT- No edema, beats b/l, Neuro - ¾ DTR on Right side, ftn in place, gentle sensation loss to touch and temperature on right half of body, negative hoffman, CN II-XII in place Skin- No jaundice CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment

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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? Irresistible Syphilis Drugs Alcohol (Wernike)

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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment What would we like to request?

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

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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

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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Chest X-beam No smoothing of diaghram Subcostal edges clear No proof of pneumonia EKG NSR CT Brain No drain, infarct or mass movement

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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 shortcoming, beginning today and enhancing, doubtlessly TIA however should r/o CVI On ASA Will include Plavix 75mg day by day Counseled quiet about smoking suspension Lipid board Gerd Zantac 150mg offer

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Thank you! Questions, remarks, concerns?

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