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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?. History of Present Illness. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS

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Chief complaint l.jpg
Chief Complaint

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



Slide4 l.jpg

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 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.


Slide5 l.jpg

  • 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


Slide6 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

Medications

Zantac

Prilosec

ASA

Flomax

Allegra

Celebrex


Slide7 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

Allergies

Residents who ask too many questions


Slide8 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

Social History

40 pack year smoking history

Occasional alcohol


Slide9 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

Family Medical History

Paternal grandmother had a CVI at 60


Slide10 l.jpg

Review of systems

General:weight change, fever, chills, weak,

slurring words

Head:headache, nasuea, vomitting

Respiratory:SOB, wheeze, no cough or URI

Cardiac:HTN, murmurs, hx angina, palpitations

GI:appetite, n/v, incont., no const/diarrhea,

frequency, hesitancy, urgency, dysuria

hematuria, incont., stones,

no dyspareunia, no discharge

MSK:muscle weakness, flank pain, muscle

cramps, right sided weakness not

involving face

Neuro:parasthesias, loss of sensation

Psychiatric- Pt is not anxious or depressed

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment


Slide11 l.jpg

Physical Exam

VS- 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 face

CV- RRR w/o murmurs or rubs, clicks or gallops

RESP- Clear to auscultation bilaterally, no wheezes,

rales or crackles

Abdomen- Soft, NT, no rebound, ND, no masses

GU- No discharge, bleeding

MSK- 4/5 MMT on R UE and LE, no gait disturbances

TTA T5-8 on left

EXT- 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


Slide12 l.jpg

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?Infectious Syphilis

Drugs Alcohol (Wernike)


Slide13 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

What do we want to order?


Slide14 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

Labs

CBC

Chemistry

VDRL

B12, Folate

Sed rate


Slide15 l.jpg

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


Slide16 l.jpg

  • CC

  • HPI

  • PMHx

  • MEDS

  • Allergies

  • SocHx

  • FMHx

  • ROS

  • Physical Exam

  • Differential

  • LABS

  • Radiological

  • Diagnosis

  • Treatment

Chest X-ray No flattening of diaghram Subcostal angles clear No evidence of pneumoniaEKG NSRCT Brain

No bleed, infarct or mass shift


Slide17 l.jpg

  • 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 weakness, starting today and improving, most likely TIA but must r/o CVIOn ASAWill add Plavix 75mg dailyCounseled patient about smoking cessationLipid panel

  • GerdZantac 150mg bid


Thank you l.jpg
Thank you!

  • Questions, comments, concerns?


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