CHIEF COMPLAINT: Weakness
HISTORY OF PRESENT ILLNESS:
Site-
Onset-
Character-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
New weakness-
Altered sensation-
Vision problems-
Impaired speech/swallowing-
Decreased ability to stand/walk-
Falling-
Altered mental status-
Dominant hand-
Baseline-
Similar symptoms before-
Nausea- , Vomiting- , SOB- , CP-
Headache- , Passed out- , Seizure- , Dizzy-
Cough- , Fever/chills- , Dysuria-
ER Tx given-
PAST MEDICAL HISTORY:
MI CAD HTN DM Stroke Migraine Seizures
Catheterization Echo
Pacemaker CA PUD PVD DVT COPD Asthma Gallstones
EGD Colonoscopy
PAST SURGICAL HISTORY:
CABG Cholecystectomy Hernia GSW Hysterectomy
MEDICATIONS:
ALLERGY: NKDA
FMH:
CAD<> 55 yo DM Stroke HTN CA Migraine
SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- no heavy occasional last drink
Smoker: no
Illicit drugs- no cocaine heroin marijuana
REVIEW OF SYSTEMS: unremarkable apart from above symtpoms
PHYSICAL EXAM:
VITALS:
SpO2- Initial vitals-
GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal
LABS:
N= B= L= AG= LFT
CPP x 1 -negative
CT head:
CXR:
EKG:
ASSESSMENT:
-Weakness due to
*TIA
*CVA
*Subdural hemorrhage
-Swallow evaluation at bedside-
PLAN:
-CPP x 2 q 8 hr
-EKG now and in AM
-ASA
-UA
-O2 to keep SpO2 > 92%
-Tylenol 650 mg PO q 4-6 hr PRN headache
-Vasotec 1.25 mg IV q 6 hr PRN SBP> 170
-Neurology consult
-2D Echo
-Carotid duplex
-MRI/MRA
-Pepcid 20 mg IV BID, Heparin 5000 U SC BID
-CBCD, BMP in AM
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