Identifying Data:

Full Name: K.O.

Age: 34

Sex: Male

Marital Status: Single

Race/Nationality: Japanese  

Address: Queens, NY

Date of Birth: XX/XX/1987

Date and Time: 10/12/2021 11:30 AM 

Location: New York Presbyterian Hospital Queens   

Source of Information: Self

Source of Referral: Self

Reliability: Reliable

Mode of Transport: EMS

Chief Complaint: right sided weakness

History of Present Illness: 

34 y/o M with a PMHx of HTN not currently on any medications, who presented to the ED via EMS three days ago for right sided weakness that started at 1:30 PM. The patient stated he woke up at 10:30 AM on 10/10, felt fine but then went back to sleep at 11:30 AM, last known normal, because he felt tired. Patient then woke up at 1:30 PM and had right upper extremity and right lower extremity weakness, nausea, and dizziness, at which time he called EMS. He denied any fever, chills, blurry vision, chest pain, shortness of breath, palpitations, abdominal pain, vomiting, neck pain, headache, or any other symptoms at that time.

Patient was seen in the ED by stroke team and was found to have right hemiplegia, dysarthria, partial gaze palsy to right side and a right sided facial droop with a NIHSS of 13. Initial blood pressure was 166/128, repeat 134/104. CT head was negative for acute infarcts or hemorrhages at 3:50 PM. CTA head/neck was negative for LVO and CT perfusion was negative. Patient received tPA in the emergency department, despite being outside the tPA window, due to concerning symptoms consistent with ischemic stroke. No significant labs except a lactate of 4.2, requiring IV fluids.

The patient was admitted to the MICU for neurological monitoring until yesterday, with no significant complications. Patient was found to be hypoxic to 90% while sleeping, most likely secondary to obstructive sleep apnea, and was given supplemental oxygen by nasal canula.  Patient has since been transferred to the stroke unit with telemetry monitoring.

Patient seen at bedside today. No acute events overnight. He states he feels better this morning and can move his right side with improvement. He reports no bowel movement in two days but denies any fever, blurry vision, chest pain, shortness of breath, nausea, vomiting, dizziness, or headache.

Past Medical History:

• Present illnesses:
  • Hypertension

Past Surgical History:

• Denies any past surgeries

Family History:

• Father: hypertension, unknown any other illnesses
• Mother: unknown
• Denies a family history of strokes or clotting disorders.

Medications:

• Denies taking any medications

Allergies:

• Denies any food, medication, or environmental allergies.

Social history:

• Single, lives alone in apartment.
• IT computer engineer. Able to perform all activities of daily living independently.
• Mother lives in New Jersey, father lives in Japan. Does not communicate with family.
• Habits: Denies present or past tobacco use, alcohol use or illicit drug use.
• Recent travel: Denies
• Diet: Admits to eating an unhealthy diet.
• Exercise: Denies exercising. Admits to a sedentary lifestyle.
• Sleep: Reports irregular sleep patterns. Occasionally stays up late to participate in video games.
• Sexual history: Denies being currently sexually active

Review of Systems: 

General: Denies fever, chills, weakness, fatigue, night sweats, decreased appetite, weight gain/weight loss.

Skin, hair, nails: Denies changes in texture, discoloration, excessive dryness or sweating, pruritis or changes in hair distribution.

Head: Denies current headache, dizziness, or head trauma. 

Eyes: Denies blurry vision, double vision, loss of vision, photophobia, pruritus, or lacrimation.

Ears: Denies hearing loss, discharge, tinnitus, ear pain or use of hearing aids.

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies bleeding gums, mouth ulcers, sore throat, voice changes or use of dentures. Last dental exam unknown.

Neck: Denies localized swelling/lumps, pain, or stiffness/decreased range of motion.

Respiratory: Denies shortness of breath, cough, wheezing, sputum production. 

Cardiovascular: Denies palpitations, chest pain, leg edema, hypertension, irregular heartbeat, syncope or known heart murmur. 

Gastrointestinal: Admits to constipation. Denies abdominal pain, abdominal distention, nausea, vomiting, hematemesis, diarrhea, hemorrhoids, rectal bleeding.

Genitourinary: Denies dysuria, hematuria, hesitancy, flank pain, nocturia, oliguria, polyuria, frequency, urgency, incontinence.

Musculoskeletal: Admits to unsteady gait. Denies muscle or joint pain, back pain, redness, stiffness, or deformities.

Peripheral vascular exam: Denies intermittent claudication, peripheral edema, coldness or trophic changes, varicose veins, or color changes.

Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions or a history of DVT/PE.

Neurologic: Admits to loss of strength of right upper and right lower extremities and ataxia. Denies dizziness, lightheadedness, headaches, sensory disturbances, changes in cognition/memory, LOC, or numbness.

Psychiatric/Behavioral: Denies sleep disturbance, depression, suicidal ideations or seeing a mental health professional.

Physical Exam: 

VS: T 98.2 F, BP 160/123, HR 86 bpm, RR 16 unlabored, O2 sat 95% on room air, Ht 180.3 cm, Wt 122.1 kg, BMI 37.56 

Gen: Awake, alert, and oriented to person, place and time. Well-appearing, obese male.

Skin: Warm and moist, no rash, bruises, or pallor. Normal skin turgor. Non-icteric skin.

Head: Normocephalic, atraumatic.

Eyes: Symmetric OU. No eyelid swelling, ptosis or lesions. Sclera non-icteric. PERRLA. EOMI, no gaze palsy.

ENT: Mucous membranes moist. No erythema or exudates in oropharynx. Uvula midline. Trachea midline, thyroid non-enlarged. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. Radial pulses, DP/PT pulses 2+ bilaterally. Capillary refill less than 2 seconds bilaterally. Extremities warm and well-perfused with no edema.

Respiratory: Lungs clear to auscultation bilaterally. No respiratory distress. 

Abdomen: Bowel sounds present in all quadrants. Soft, nontender, nondistended with no rebound or guarding.

Extremities: No ecchymosis, atrophy, or deformities.

Neuro: Alert and oriented to person, place, and time.Able to name, repeat and follows commands. No aphasia. Mild dysarthria. Right facial droop. Slow gait leans towards right.

Cranial Nerves:

CN II: visual fields intact

CN III, IV, VI: PERRL, EOMI, no nystagmus.

CN V: sensation intact to light touch

CN VII: mild facial droop on right side

CN VIII: hearing intact to voice 

CN IX, X: palate elevates symmetrically

CN XI: trapezius and SCM strength 5/5 and equal bilaterally

CN XII: tongue midline on protrusion

Motor: Normal tone throughout. Fine finger movements slightly slowed on right. No tremors. 5/5 strength proximal RUE, 4/5 strength distally RUE. RLE 4/5 proximally, 4/5 distally. 5/5 strength LUE/LLE.  Mild right pronator drift. Decreased right fine finger movement 

Sensation: Decreased sensation to right lateral thigh. Intact sensation elsewhere.  

NIHSS:

Level of Consciousness 1a: Alert (0)

Level of Consciousness Questions 1b: Answers both correctly (0)

Level of Consciousness Commands 1c: Performs both tasks correctly (0)

Best Gaze 2: Normal (0)

Visual 3: No visual loss (0)

Facial palsy 4: Minor paralysis (1)

Motor arm 5: Drift, but doesn’t hit bed (1)

Motor leg 6: Drift, but doesn’t hit bed (1)

Limb ataxia 7: present in one limb (1)

Sensory 8: Mild-moderate loss: less sharp/more dull (1)

Best language 9: Normal (0)

Dysarthria 10: Mild to moderate dysarthria (1)

Extinction and Inattention 11: No abnormality (0)

Total: 6

Glasgow Coma Scale:

Eye Response: 4, open spontaneously

Verbal Response: 5, oriented, converses

Motor Response: 6, obeys verbal command

GCS Score: 15

Differentials:

• Ischemic stroke
• Intracranial hemorrhage
• Brain mass/tumor

Labs as of 10/10:

• CBC
  • WBC: 10.07
  • Hemoglobin: 17.2
  • Hematocrit: 48.1
  • MCV: 87,8
  • MCH: 31.4
  • MCHC: 35.8
  • RCDW: 12.1
  • Platelets: 379
• BMP   
  • Sodium: 140
  • Potassium: 4.1
  • Chloride: 98
  • Carbon dioxide: 25
  • BUN: 13.9
  • Creatinine: 1.01
  • Glucose: 183
  • Anion gap: 17
  • Calcium level total: 9.8
  • BUN/Creatinine ratio: 14
• Live function panel
  • Alkaline phosphatase: 86
  • AST: 25
  • ALT: 57
  • Protein total: 7.5
  • Albumin:4.8
  • Globulin:  2.7
  • Bilirubin: 1.1
  • Direct bilirubin: 0.2
  • Indirect bilirubin: 0.9
• APTT: 26.1
• Prothrombin time: 11.4
• INR: 0.99
• Lipase: 35
• Troponin    <0.010  
• Ammonia: 15
• CK: 60
• Procalcitonin: 0.07
• Hemoglobin A1C: 5.0
• TSH: 0.86
• Post venous EPOC
  • pH: 7.36        
  • pCO2: 48
  • pO2: 43
  • HCO3: 27.1
  • Total CO2: 29
  • Base Excess: 0.80
  • O2 Sat/Venous, Calc: 77     
  • Sodium W/B: 140
  • Potassium W/B: 3.9
  • CL WB: 101
  • Calcium, Ionized BG: 1.08
  • Hematocrit W/B: 51.0
  • Hemoglobin W/B: 17.3
  • Glucose: 199
  • Lactate W/B: 4.22
  • CRE WB: 0.91
  • Hemodilution: No
• Lipid panel 10/11
  • Cholesterol: 179
  • HDL: 31
  • Triglycerides: 197
  • LDL: 121 
• B12: 463
• Folate: 9
• Magnesium: 1.9
• Phosphorous: 3.4

• Urinalysis
  • Color: Yellow
  • Appearance: Clear
  • Glucose: negative
  • Bilirubin: negative
  • Ketones: negative
  • Nitrites: negative
  • Leukocyte esterase: negative
  • Bacteria: negative
  • Gravity: less than 1.045
  • WBC: 1
  • RBC: 7
  • Squamous epithelial cells: 2
  • Hyaline cast: 0
  • Blood: small
  • pH: 7.0
  • Protein: trace
  • Urobilinogen: 0.2

• SARS-CoV-2-NAAT: negative

EKG 10/11:

• NSR 87 bpm, no ST elevations or depressions.

Imaging:

• CXR: No evidence of acute cardiopulmonary disease 
• CT head without contrast: No mass effect or intracranial hemorrhage. No CT evidence of acute large territorial infarction.
• CT angiography head/neck with IV contrast: No significant vascular stenosis or occlusion in head or neck.
• CT head perfusion with IV contrast: Unremarkable exam
• Repeat CT head: No acute intracranial pathology.

Assessment/Plan: 

34 y/o M with PMHx of HTN not on medication, who presented to the ED with acute dysarthria, right sided weakness, and right facial droop. CT head, CTA and perfusion scans all negative. Patient received tPA and admitted to medicine for ischemic stroke workup. Patient is clinically improving with improvement in dysarthria, right hemiplegia, and sensation. Patient is pending further stroke workup.

Presumed Ischemic CVA:

• Right hemiplegia, right facial droop, dysarthria s/p tPA
• MRI brain pending
• PT, OT and speech and swallow evaluations pending
• Continue with 81mg ASA and Plavix 75 mg daily for three weeks, then switch to only 81mg ASA.
• Continue Atorvastatin 80mg with goal of LDL less than 100
• Permissive HTN blood pressure goal of systolic 130-160
• TTE pending, if TTE negative will obtain TEE
• Pending Transcranial doppler with bubble study
• Pending BLE US
• If confirmed stroke on MRI, will obtain hypercoagulable panel (lupus anticoagulant, factor V Leiden, factor VIII activity, homocysteine levels, protein C and S, prothrombin mutation, anticardiolipin, antithrombin III)
• Able to get out of bed with assistance

Hypertension:

• Permissive HTN, blood pressure goal of systolic 130-160, diastolic less than 105
• Increase Losartan to 100 mg from 50 mg

Dyslipidemia:

• LDL 121 and HDL 31
• Continue with Atorvastatin 80 mg

Constipation:

• Polyethylene glycol 17 grams, one packet ordered daily
• Dulcolax 10 mg daily as needed

Obstructive Sleep Apnea:

• Outpatient sleep study referral when discharged

DVT prophylaxis:

• Enoxaparin 40 mg subcutaneous daily