3/3/06 Case

Chief Complaint

• Pt is a 55 y/o caucasion male who presents with right-sided weakness that started last night.

• What questions do we want to ask this patient?

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

History of Present Illness Pt is a 55 y/o c male with history of TIA, hypercholesterolemia and smoking history who presents with right-sided weakness. He states that this began upon waking up at around 1:30 am. He noticed that he was unable to maintain balance and was disoriented and was slurring his words. He noticed that something was different and came to the emergency room. This happened before, about 5-6 years ago, but only lasted about 20 minutes. He states he began feeling better around 4-5 am. Initially he had trouble swallowing but this has since resolved. During the episode he denied any chest pain, palpitations, lightheadedness or vertigo. He does note that he drank 5-6 beers, which is unusual for him. He also denies seizure, bowel or bladder incontinence or lip lacerations.

• 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

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Medications

Zantac

Prilosec

ASA

Flomax

Allegra

Celebrex

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

AllergiesResidents who ask too many questions

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Social History

40 pack year smoking history

Occasional alcohol

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Family Medical HistoryPaternal grandmother had a CVI at 60

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Review of systems

General: weight change, fever, chills, weak, slurring words

Head: headache, nasuea, vomittingRespiratory: SOB, wheeze, no cough or URICardiac: HTN, murmurs, hx angina, palpitationsGI: appetite, n/v, incont., no const/diarrhea,

frequency, hesitancy, urgency, dysuriahematuria, incont., stones, no dyspareunia, no discharge

MSK: muscle weakness, flank pain, muscle cramps, right sided weakness not involving face

Neuro: parasthesias, loss of sensationPsychiatric- Pt is not anxious or depressed

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological

• Diagnosis• Treatment

Physical ExamVS- BP- 160/94 HR 91 R 18 T 98 Pulse ox 95%General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes, no tongue

deviation, no sensation loss on faceCV- RRR w/o murmurs or rubs, clicks or gallopsRESP- Clear to auscultation bilaterally, no wheezes,

rales or cracklesAbdomen- Soft, NT, no rebound, ND, no masses GU- No discharge, bleedingMSK- 4/5 MMT on R UE and LE, no gait disturbances

TTA T5-8 on leftEXT- No edema, pulses b/l, Neuro- ¾ DTR on Right side, ftn intact, mild sensation

loss to touch and temperature on right side of body, negative hoffman, CN II-XII intact

Skin- No jaundice

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Differential

Metabolic

Hypoglycemia

Tissue

StrokeCancer

VascularCarotid stenosisMigraine?

InfectiousSyphilis

DrugsAlcohol (Wernike)

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

What do we want to order?

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Labs

CBC

Chemistry

VDRL

B12, Folate

Sed rate

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

CBC

10.613.9 g/dl

41.5

139

Chemistry

137

4.0

103

27

14

1.7

155

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Chest X-rayNo flattening of diaghramSubcostal angles clearNo evidence of pneumonia

EKGNSR

CT Brain

No bleed, infarct or mass shift

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Diagnosis

1. Pt is a 55 year old caucasion male with right-sided weakness, starting today and improving, most likely TIA but must r/o CVIOn ASAWill add Plavix 75mg dailyCounseled patient about smoking cessationLipid panel

2. GerdZantac 150mg bid

Thank you!

• Questions, comments, concerns?