3306 Case

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3/3/06 Case

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Chief Complaint

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

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• What questions do we want to ask this patient?

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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

History of Present Illness
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 130 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.
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• 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
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Medications
Zantac Prilosec ASA Flomax Allegra Celebrex
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
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• ROS
• Physical Exam
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• Radiological
• Diagnosis
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Allergies Residents who ask too many questions
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• CC
• HPI
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• MEDS
• Allergies
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• ROS
• Physical Exam
• Differential
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• Radiological
• Diagnosis
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Social History
40 pack year smoking history Occasional alcohol
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
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Family Medical History Paternal grandmother had a
CVI at 60
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• CC
• HPI
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• Allergies
• SocHx
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• Physical Exam
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• LABS
• Radiological
• Diagnosis
• Treatment

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
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

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
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Differential
Metabolic Hypoglycemia Tissue Stroke Cancer Vas
cular Carotid stenosis Migraine?Infectious Sy
philis Drugs Alcohol (Wernike)
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

What do we want to order?
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Labs
CBC Chemistry VDRL B12, Folate Sed rate
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CBC
13.9 g/dl
10.6
139
41.5
Chemistry
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137
103
155
4.0
27
1.7
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• CC
• HPI
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• 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 NSRC
T Brain No bleed, infarct or mass shift
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• 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

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Thank you!

• Questions, comments, concerns?