DATE OF ADMISSION: MM/DD/YYYY
PRESENTING COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who was brought to the emergency room by paramedics after an episode of syncope. At present, the patient seems to be slightly confused. She is unable to provide accurate information. According to the ER records, she fell at home, and her friend called the ambulance and brought her to the emergency room, but the patient does not have any recollection that she came to the emergency room by ambulance. She thinks that her friend brought her over.
The patient says she was having elevated blood pressure. She has been taking her medicine, and for last three days, she has been having increasing headache and she attributed that to her elevated blood pressure, but the patient was also having nausea and vomiting at home.
At present, at the time of interview, the patient says she is not having any headache, and she feels better and back to normal. No syncope since that time.
PAST MEDICAL HISTORY: Hypertension, CVA, hypercholesterolemia, and depression.
PAST SURGICAL HISTORY: Appendectomy and hysterectomy.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Clonidine 0.3 mg three times daily, Prozac 40 mg p.o. daily, aspirin 325 mg p.o. daily, and Prilosec 20 mg p.o. daily.
SOCIAL HISTORY: The patient lives with her elderly mother. The patient cannot remember the name of her primary care provider. The patient says she does not smoke and does not drink alcohol.
FAMILY HISTORY: Mother has a history of CAD and diabetes. The patient’s father also has diabetes. The patient has one brother, who has diabetes.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies any dizziness or weakness. Denies any blurred vision.
HEENT: No nasal congestion, rhinorrhea or epistaxis.
CARDIOVASCULAR: Denies any palpitations, chest pain, dyspnea, orthopnea or PND.
RESPIRATORY: Denies any shortness of breath. No cough or hemoptysis.
GASTROINTESTINAL: Denies any abdominal pain, nausea or vomiting, diarrhea or constipation.
GENITOURINARY: No dysuria, frequency or urgency or hematuria.
MUSCULOSKELETAL: Denies any back pain, neck pain or calf pain.
DERMATOLOGY: Denies any rash or discoloration.
NEUROLOGICAL: The patient is complaining of syncopal episode at home. Denies any paresthesias or weakness. The patient was also having headache at home, which has resolved now.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, sitting up in the bed comfortably, not in any acute distress.
VITAL SIGNS: Maximum temperature since admission 96.4, pulse 50, respirations 20, blood pressure 126/52, and admission weight 72 kg.
HEENT: Moist mucous membranes, anicteric sclerae.
NECK: Supple. No jugular venous distension or carotid bruits noted.
HEART: S1, S2 audible.
LUNGS: Clear breath sounds bilaterally. No wheezing or rales.
ABDOMEN: Soft and nondistended. No mass, no guarding.
GENITOURINARY: Deferred.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGICAL: The patient is having preference of her gaze to the right, and the patient’s vision is blurred, but the patient denies any blurry vision. While talking to the patient, interviewing her, asked the patient to close one eye and tell the pictures on the TV, which is approximately 6 feet away from her, and the patient is unable to recognize the picture. The patient says she can see a shadow on the TV. When asked to write something on the paper, she is preferring the right visual field. Pupils are round and reactive, and extraocular movements are intact. No gross sensory or motor deficit is noticed. GCS is 15.
INITIAL DIAGNOSTIC AND LABORATORY DATA: In the emergency room, the patient had a CT of the head without contrast, which was read by Radiology as acute cortical infarct in the occipital region.
A 12-lead EKG showed sinus bradycardia with a heart rate of 50, short PR interval. No acute ST segment elevation or depression.
Echocardiogram was ordered this morning, which shows normal ejection fraction of 50-60%, mild to moderate tricuspid regurgitation, and the patient’s left atrium is mildly dilated on the echocardiogram.
MRA of the brain shows complete or near complete occlusion of the right posterior cerebral artery, mild atheromatous irregularity of the left posterior cerebral artery, small aneurysm approximately 2 mm at the right posterior cerebral artery.
MRI of the brain shows moderate to large size acute cortical infarct in the right posterior cerebral artery distribution. Multiple additional small foci of acute ischemia are noted involving the white matter of the left cerebral hemisphere. Findings suggestive of embolic disease.
CPK 244, CK-MB 3.42, troponin 0.41.
Sodium 134, potassium 3.2, chloride 96, CO2 of 26, glucose 192. BUN 52, creatinine 1.3. Alkaline phosphatase 58, total bilirubin 1.3. AST 42, ALT 28.
Urinalysis normal. Urine drug screen negative. WBC count 11.6, hemoglobin 13.6, hematocrit 39.8, platelets 298. TSH 1.03. Repeat CPK is 188, CK-MB 2.82, and troponin 0.392.
Total cholesterol 210, triglycerides 300, HDL 40, LDL 112. Repeat electrolytes this morning show potassium down to 2.7.
CLINICAL IMPRESSION:
1. Non-ST myocardial infarction.
2. Occipital ischemic infarct.
3. Renal insufficiency.
4. Bradycardia.
5. Hyperlipidemia.
RECOMMENDATIONS:
1. The patient was evaluated in the emergency room and admitted to the ICU. Considering the large area of infarct, the patient is receiving aspirin 325 mg p.o. daily. Plavix and Lovenox are not given because of the risk of conversion of the stroke to a hemorrhagic stroke. Neurology consult is obtained. Most of the workup for her stroke is completed. At present, the patient will benefit from TEE. The service is not available.
2. We have discussed the patient’s CT and MRI findings and physical findings with Dr. John Doe, and considering the bed situation, Dr. John Doe has advised to transfer this patient to the regular medical floor where she can be managed by hospitalist instead of transferring the patient to the ICU since hemodynamically and neurologically the patient is stable.
3. That recommendation was followed by a call to on-call hospitalist. Case was discussed with Dr. Jane Doe at this time, and according to Dr. Jane Doe, normally they do not take any transfers after 3 p.m. and we should try to transfer her during the daytime when there is more help available to accept the transfer.
4. At present, the patient will be transferred out from the ICU to the telemetry floor.
5. We will continue to monitor her closely. Continue on aspirin. Start the patient on simvastatin 40 mg p.o. daily.
6. Continue to monitor cardiac enzymes. Continue to monitor the patient’s blood pressure. Repeat cardiac enzymes and EKG in the morning.
7. We will discuss with on-call hospitalist in the morning for possible transfer and further cardiology evaluation as well since these services are not available. The patient will also need TEE, which is not available during the weekends here.
