CC: “I think I had a mini stroke”

HPI:

77 y/o female with PMH of HTN, CAD s/p stents 2017, hypothyroid, anxiety, glaucoma, and mitral valve regurgitation presenting with dysarthria x3 days ago. Patient states 3 days ago as she was eating lunch with her family, she suddenly “couldn’t get the words out”. Patient states this lasted for about 15 minutes and she was able to walk and move all extremities during the episode. Patient admits to intermittent heart palpitations which are happening more frequently. Patient states she went to rest afterwards. She attributes her symptoms to exhaustion and pain medication she has been taking for a left laparoscopic meniscus repair 1 week prior. Patient states she was taking Tramadol for her pain but stopped and switched to Tylenol because it was causing her abdominal pain. The next day, she consulted her PCP who recommended her to seek further evaluation here. Denies headaches, tingling, numbness, syncope, focal weakness, visual changes, slurred speech, CP, SOB, fever, chills, abdominal pain.

PMH/PSH:

HTN

CAD s/p stents 2017

Mitral valve regurgitation 

Hyperlipidemia

Hypothyroidism

Glaucoma

Allergies: NKDA or environmental allergies 

Meds: 

Dorzolamide-timolol 0.05% ophthalmic solution 1 drop in affected eye q12hr

ASA 81 mg PO qD

Levothyroxine 100 mcg PO qD

Metoprolol  100mg PO qD 

Rosuvastatin 20 mg PO qD

Alprazolam 0.05mg PO qD PRN

Family History: 

Mother deceased. Hx diabetes, HTN.

Father deceased. Hx HLD.

Social history: non smoker. ETOH 1 glass wine on weekends. Retired school teacher.

ROS:

Constitutional: Denies weight loss, fatigue, night sweats

Head: denies LOC, headaches, trauma, changes in vision

Neurologic: see HPI.

Eyes: denies itching, tearing, visual acuity issues.

ENT: denies tinnitus, hearing loss, vertigo, stuffiness, sore throat or neck pain.

Cardiac: Admits to palpitations. Denies murmurs, chest pain.

Pulmonary: Denies cough, hemoptysis, fibrosis.

Hematology: Denies bruising, petechiae, or purpura.

Skin: Denies edema, bruises or excoriations.

GI: Denies abdominal pain, change in bowel habits.

Musculoskeletal: Left knee pain s/p meniscus repair. 

Psychiatric: Admits to anxiety. Denies stress, depression or mood changes.

Physical Exam

Vitals: 140/86 pulse: 110 Resp: 18 SpO2: 99% RA. Temp 98.1. BMI 20.76 kg/m2

Labs/ imaging:

BMP wnl

CBC 6.41>13.2/39.7<403*

TSH wnl

Troponin wnl

CPK  wnl

BNP wnl

D-Dimer 0.67*

EKG: atrial fibrillation, HR 139

MRA carotids and circle of willis negative 

CT head without contrast: no acute intracranial abnormality 

MRI brain: acute cortical infarct of posterior parietal lobe*

General: A&Ox3. In no acute distress. Well developed, good hygiene, appears stated age.

Head: Normocephalic, no scars or lesions or trauma.

Eyes: Symmetrical. Iris brown. No erythema over sclera and conjunctiva. No ptosis, icterus. EOMI without nystagmus. PERRL. Fundoscopic exam: Vessels sharp, no cotton-wool spots or papilledema. 

Ears: Symmetrical. No TTP over tragus, lobe or helix. AU-EAC unobstructed. TMs pearly gray, no injection or bulging TM noted.

Nose: Septum midline. Patent airway. No rhinorrhea. Inferior turbinates observed. No hematoma, discharge or foreign body.

Mouth/Throat: Teeth intact and no evidence of loose teeth or dentures. Tongue, uvula midline. Tonsils present grade 2. Uvula midline. No PND.

Neck: Supple, no palpable goiter or TTP.

Lymph nodes: No palpable lymphadenopathy. No TTP.

Lungs: No adventitious lung sounds.

Heart: Irregularly irregular. Tachycardic. S1, S2. No gallops, rubs or murmurs.

Abdomen: No straie, scars or visible hernias present. Bowel sounds +, Soft, NT ND. No guarding, rigidity, masses or organomegaly appreciated. 

Gentourinary: deferred.

Skin: Noted clubbing of fingers. No edema, ecchymosis or rashes.

Extremities: Mild left knee swelling s/p meniscus repair. No lower extremity edema.

Neurological exam: Cranial nerves: II-XII grossly intact. 

Assessment

77 y/o female with PMH of HTN, CAD s/p stents 2017, hypothyroid, anxiety, glaucoma, and mitral valve regurgitation presenting with dysarthria x3 days ago likely secondary to ischemic stroke vs TIA.

Patient is well appearing,  tachycardic in 110s.

 

Plan

CVA – ischemic 

• Dysarthria resolved after 15 min, no other symptoms, head CT negative, not likely hemorrhagic 
• MRI brain acute cortical infarct posterior parietal lobe
• Not candidate for thrombolytic therapy 
• Elevated d-dimer: f/u with doppler of lower extremity to r/o DVT
• MRA carotids and circle of willis negative
• EKG: atrial fibrillation HR 139. 
• F/u on echo – likely clots, possibly start on eliquis long term
• c/w cardizem, lopressor, heparin, crestor 
• Neuro checks, Neuro consult

HTN/HLD/CAD

• c/w home meds

Hypothyroid

• c/w home meds

Glaucoma  – c/w home meds