06-30-2010, 01:59 PM
66 yo M c/o weakness & Facial Droop.
BP: 151/90 mmHg. Temp: 98.6 F. RR:14/min. HR: 77/min.
HPI:
60 yo M presents to the ER c/o of 20 min episode of Slurred speech, Right facial droop,
numbness/ weakness along with confusion 30 min ago.
- had same weakness wk ago that resolved in < 5 min w/o intervention.
- Now Feeling completely well since Sxs resolved complelety w/o tx.
- Denies: headche, Fever/chill, seizures, altered mental status, recent fall/vertigo, chest pain, palpitation/SOB.
Med: Lisinopril, Asprin, Metformin, Atorvastatin. NKDA.
PMH/PSH: HTN. DM. Hyperlipidemia.
FH: not known. Pt is adopted.
SH: No EtOH/Illicit drug. Smokes 1 PPD x 50 yrs.
PE:
Pt is concern but not in acute distress.
VS: WNL except Bp of 151/90 mmHg.
HEENT: AT/NC. PERRLA. EOMI. Fundoscopy NL.
NECK: supple. No Mass/JVD/ Bruit. Thyroid NL.
CHEST: Nl Chest sound BL.
HEART: RRR. S1S2 NL. No M/G/R. PMI not displaced.
EXTREMITIES: No Rash/edema/etenderness BL. Femoral pulse NL no Bruit observed BL.
NEURO: Pt is Oriented x 3. CN II - XII intact. DTRs 2+ BL. Motor strength 5/5 in all muscle
group BL. Sensation intact to dull/sharp/vibration. Babinski neg. Romberg neg. Gait NL.
DX:
TIA
Hypoglycemia
Multiple Sclerosis.
Cerebral Hemorrhage
Brian Tumor.
TESTS:
CBC. Electrolyte. Glucose. Serum
Calcium.
CT scan of brain
PT/aPTT/BT.
Lipid Profile
ECG/ Echocardiogram.
BP: 151/90 mmHg. Temp: 98.6 F. RR:14/min. HR: 77/min.
HPI:
60 yo M presents to the ER c/o of 20 min episode of Slurred speech, Right facial droop,
numbness/ weakness along with confusion 30 min ago.
- had same weakness wk ago that resolved in < 5 min w/o intervention.
- Now Feeling completely well since Sxs resolved complelety w/o tx.
- Denies: headche, Fever/chill, seizures, altered mental status, recent fall/vertigo, chest pain, palpitation/SOB.
Med: Lisinopril, Asprin, Metformin, Atorvastatin. NKDA.
PMH/PSH: HTN. DM. Hyperlipidemia.
FH: not known. Pt is adopted.
SH: No EtOH/Illicit drug. Smokes 1 PPD x 50 yrs.
PE:
Pt is concern but not in acute distress.
VS: WNL except Bp of 151/90 mmHg.
HEENT: AT/NC. PERRLA. EOMI. Fundoscopy NL.
NECK: supple. No Mass/JVD/ Bruit. Thyroid NL.
CHEST: Nl Chest sound BL.
HEART: RRR. S1S2 NL. No M/G/R. PMI not displaced.
EXTREMITIES: No Rash/edema/etenderness BL. Femoral pulse NL no Bruit observed BL.
NEURO: Pt is Oriented x 3. CN II - XII intact. DTRs 2+ BL. Motor strength 5/5 in all muscle
group BL. Sensation intact to dull/sharp/vibration. Babinski neg. Romberg neg. Gait NL.
DX:
TIA
Hypoglycemia
Multiple Sclerosis.
Cerebral Hemorrhage
Brian Tumor.
TESTS:
CBC. Electrolyte. Glucose. Serum
Calcium.
CT scan of brain
PT/aPTT/BT.
Lipid Profile
ECG/ Echocardiogram.