Identifying Data:

Patient: Mr. DY

Age: 75 y/o

Sex: Male

Date & Time of encounter: November 16, 2021            9:00AM

Location: NYP Emergency Department. Queens, NY

Race: Asian

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: “I think I had a stroke” starting at 3AM

History of Present Illness:

75 y/o male with PMH of CAD s/p PCI x5, HTN, complete heart block s/p PPM, GI bleed, b/l knee replacement, depression, BIBA with complaints of moderate right upper and lower extremity numbness that began at 3AM and has been constant since. He complains of associated weakness in his right hand, stating he cannot grip objects as well as usual. Patient also notes he is walking with a limp, and feels his balance is “off” due to the RLE numbness. He also c/o mild facial numbness only on the right side, excluding the forehead. Pt reports taking 600mg aspirin around 4AM, which did not improve his symptoms. No aggravating factors. He denies head trauma, syncope, falls. Pt is compliant with his medications. Of note, he also mentions feeling more depressed lately due to his personal and sister’s health problems. Otherwise, the patient denies dizziness, lightheadedness, headache, visual disturbances, tingling, back pain, chest pain, palpitations, or SOB.

Past Medical History:

CAD s/p PCI x5 – 2013. Pt sees cardiologist regularly.

Complete heart block s/p PPM placement 2018.

HTN – not well controlled. (Pt reports SBP ranging 130s-150s at home)

GI bleed – 2015

Depression – patient has not sought professional help

Immunizations – Up to date (including COVID booster), except this year’s flu vaccine.

Colonoscopy: last one 5 years ago, at that time had polyps removed. 

Denies recent hospitalizations.

Past Surgical History:
Bilateral knee replacement 2010

Denies past blood transfusions. Denies history of stroke or DVT.

Medications: 

Aspirin 81mg PO daily

Amlodipine 10mg PO daily

Lipitor 20mg PO daily

Vitamin D supplement PO daily

Fish oil supplement PO daily

Vitamin B complex PO daily

Magnesium supplement PO daily

Allergies:

Denies any drug, environmental, or food allergies.

Family History:

Noncontributory.

Social History:

Mr. DY lives by himself. He can complete ADLs without assistance. He is retired.

Habits – Drinks 1 cup of caffeine weekly. Denies smoking history. Denies alcohol use. Denies history of illicit substance use.

Sleep – no complaints

Travel – No recent travel.

Review of Systems:

General – Denies recent fever, chills, weight loss/gain, fatigue, night sweats, or change in appetite.

Skin/nails – Denies rash, new moles, erythema, change in pigmentation, changes in hair distribution, or wounds.

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes –Denies visual disturbances, photophobia, itchiness, redness, tearing, or discharge.

Ears –Denies change in hearing, tinnitus, otalgia, discharge. No hearing aid use.

Nose – Denies congestion, discharge, epistaxis, itchiness.

Mouth/throat – Denies sore throat, difficulty swallowing, bleeding gums, dryness, ulcers, tongue pain, swelling.

Neck – Denies pain, stiffness, limited ROM, lumps, injury/trauma.

Pulmonary – Denies SOB, DOE, cough, wheezing, cyanosis, orthopnea, PND, hemoptysis. Sleeps with 1 pillow for comfort.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling, syncope.

GI – Denies abdominal pain, nausea, vomiting, diarrhea, constipation, excessive belching, rectal bleeding. No recent changes in BM.

Genitourinary – Denies dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous – (+)weakness. (+)numbness. (+)gait change. (+)Denies tingling, seizures, confusion.

Musculoskeletal –  Denies body aches, back pain, joint pain, claudication.

Hematologic – Denies history of DVT/PE, blood transfusions, bruising.

Endocrine – Denies polydipsia, polyphagia. Denies heat or cold intolerance.

Psychiatric – (+)depression. Denies suicidal thoughts, or hallucinations.

Physical Exam:

Vital signs:      BP: Seated                  L-arm: 154/86             R-arm: omitted due to IV

RR:      16 breaths/min, unlabored                 

Pulse: 64  bpm, regular                     

T:        98.6 degrees F (oral)

O2 Sat: 97% on room air

Height: 67 inches        Weight: 140 lbs.       BMI: 21.9

General: Pt alert, oriented. No acute distress. Well nourished. Looks stated age.

Skin: (+)slightly decreased temperature to right hand and right foot.Otherwise skin is warm & moist. poor skin turgor (pt is elderly). No ecchymosis. Nonicteric, no other lesions noted, no tattoos. No rashes appreciated. (+)IV drip in right antecubital area, without signs of inflammation.

Hair:  (+)alopecia (appropriate to male pattern baldness)

Nails:  no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic, nontender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. (+)Mild amount of cerumen in auditory canals bilaterally. No discharge or other foreign bodies in external auditory canals.  Right and left TM pearly white and fully intact with cone of light in good position. Auditory acuity intact to whispered voice. Weber midline / Rinne reveals AC>BC bilaterally.

Nose –Symmetrical / no masses / lesions / deformities / trauma / discharge. (*Deferred due to COVID-19*).

Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. 

Septum midline without lesions / deformities / injection / perforation.   No foreign bodies.

Sinuses – Nontender to palpation and percussion over the frontal, ethmoid and maxillary sinuses.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist.

No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars.

No gingival hyperplasia or recession.

Tongue is midline. No discharge, masses or lesions. Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, foreign bodies. Tonsils are grade I. Mallampati Class I.

Neck – Full ROM. Supple. Non-tender to palpation. No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. No cervical adenopathy noted. Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes – (+)Pupils dilated to ~5mm, symmetric. Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRLA.
Visual fields full OU.  EOMs intact with no significant nystagmus.
Fundoscopy – Red reflex intact OU. Could not assess cup to disk ratio. No hemorrhages or exudates visualized.

Visual acuity uncorrected: 20/40 OD, 20/40 OS, 20/40 OU.

Chest/Pulmonary: (+)elevation to right upper chest where PPM was placed, no erythema, tenderness, discharge, or warmth. Chest is otherwise symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. Chest nontender to palpation throughout. Lungs CTA and percussion bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds. Chest expansion and diaphragmatic excursion symmetric. Tactile fremitus symmetric throughout.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. PMI in 5^th ICS in mid-clavicular line.

Carotid pulses are 2+ bilaterally without bruits. JVP is 2cm above the sternal angle with head of the bed at 30°.

Abdomen: Abdomen nontender to palpation, no guarding or rebound. Tympanic throughout. No hepatosplenomegaly. Abdomen flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. No renal, iliac, or femoral bruits. No CVA tenderness noted.

Genitourinary: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Rectal: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 2 stage commands. Is able to repeat words and name objects. Speech is of appropriate quantity, rate, volume, flow, and articulation.

(+)depression. No SI/HI, no feelings of rage or anxiety.

Conversation progresses logically towards a goal. No delusions, hallucinations, phobias, obsessions.

Insight and judgement intact/appropriate.

Oriented to name, date, time, location. Digit span to 5 numbers. Serial 7s x5. Pt able to spell “world” forward and backwards. Remote and recent memory seemed intact (but could not verify). Recall 3/3.

Able to name president. Follows 3 stage commands. Calculating ability intact. Abstract thinking and constructional ability intact.

Neurologic:

Cranial Nerves – Patient can perceive odors bl and identify them. See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. Convergence of eyes. No ptosis. Bilateral blinking with corneal reflex. Facial sensation present and equal bilaterally to light touch and pain. Strong jaw contraction. Intact taste to sweet, salt, sour, and bitter. Symmetric and fluid facial movements. No difficulty with BMP speech sounds. Strong eye muscles that hold eye closed against resistance. See “Ear” for CN VIII.

Intact taste to sour and bitter. Pharyngeal muscles contract during gag reflex. Soft palate rises and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop.

Strong neck and should muscles against resistance bilaterally. Strong and symmetric tongue. No difficulty with LTND speech sounds.

Peripheral Neuro –

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout, including grip strength.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory

Intact to light touch, sharp/dull, and vibratory sense throughout. Sensation symmetric. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes

2+ throughout, negative Babinski, no clonus appreciated

                                    R          L                                              R          L

Brachioradialis              2+        2+                    Patellar             2+        2+

Triceps                          2+        2+                    Achilles             2+        2+

Biceps                         2+        2+                    Babinski           neg       neg

Abdominal                    2+/2+    2+/2+                Clonus          neg       neg

Meningeal Signs

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Differential Diagnoses:

• Ischemic stroke – most likely given patient history/presentation
• Hemorrhagic stroke – less likely, but considered given Hx of HTN.
• TIA – considered given symmetric, 5/5 motor strength and sensation on exam.
• Hypoglycemia – unlikely given unilateral symptoms but considered with numbness.
• Post-ictal paralysis – unlikely, pt did not report seizure or LOC (but perhaps he forgot).
• Multiple Sclerosis – unlikely due to atypical presentation and age
• Anxiety – pt reports feeling more depressed lately.