Identifying Data:
Full Name: KC
Address: Queens, NY
Date of Birth: xx/xx/1959
Date & Time: 7/13/2022
Source of Information: Self
Reliability: Reliable
Chief Complaint: “I had trouble speaking when I was at the doctor’s office this afternoon.” X 30 minutes
History of Present Illness:
63 year old male with PMH of HTN, HLD, CAD s/p 3 stents, presenting to the ED as a stroke activation at 8pm due to episode of expressive aphasia. Patient was at his PCP’s office at around 2pm today and noticed that he had difficulty finding his words while trying to talk to the front desk. He knew what he wanted to say but couldn’t say it. Patient also reported he felt “uneasy” and “tired” at that time, so he decided not to see his PCP and drove back home himself. Patient states that this episode of expressive aphasia lasted for about 30 minutes. Per patient, his last known normal was around 1:30pm. When patient’s wife got home at around 7pm, she noticed that the patient was not himself and looked tired. Therefore, the wife decided to call EMS.
In the ED, patient stated the tiredness has improved. He reported a dull headache across the forehead that developed about 2 hours ago. He described the headache as throbbing and intermittent, at a severity of 3/10. Denies aggravating or alleviating factors. Denied chest pain, palpitation, SOB, facial droop, numbness or tingling, weakness, loss of consciousness, fall, head trauma, and vision changes.
Past Medical History:
Hypertension
Hyperlipidemia
Coronary artery disease s/p 3 stents
Past Surgical History:
PCI x 3 (2019, 2017, 2010)
Medication:
Aspirin 81 mg, PO, daily
Atorvastatin 10 mg, PO, daily
Amlodipine 5mg, PO, daily
- Patient reported that he doesn’t take his blood pressure medication at home.
Allergies:
NKDA
Denied food or environmental allergy
Family History:
Mother: 88, HTN, DM, CAD
Son: 34, alive and well
Social History:
Habits: Denies alcohol, tobacco and illicit drug use.
Travel: Denied recent traveling
Marital History: Widowed
Sexual History: Not sexually active. Denies history of STD
Occupation: Home care attendant
Home: Patient is living with his wife. Independent in all ADLs and IADLs.
Review of System:
General –Denied recent weight change, fatigue, fever, and night sweats
Skin – Denied moles, change of skin texture, itchiness.
Head – Admitted to headache. Denied light-headedness, recent head trauma.
Eyes – Denied visual changes.
Ears – Denied tinnitus or use of hearing aids.
Nose – Denied discharge, obstruction, epistaxis, loss of smell.
Mouth/throat – Denied sore throat, voice change.
Pulmonary system – Denied SOB, hemoptysis, and cyanosis.
Cardiovascular system – Denied chest pain or palpitation.
Gastrointestinal system – Denied abdominal pain, constipation, diarrhea.
Genitourinary system – Denied urinary frequency, urgency, oliguria and incontinence.
Nervous system – Admitted to aphasia (resolved). Denied seizure, weakness, sensory disturbances, and memory change.
Musculoskeletal system – Denied joint pain, back pain, muscle pain.
Endocrine system – Denied polydipsia, polyphagia.
Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
Physical Examination:
Vitals:
Temp: 97.8 F, oral
BP: 158/78
Pulse: 16, irregular
RR: 18, unlabored
O2 saturation: 99% room air
BMI: 26.6
General – AAO X3. Not in acute distress. Able to speak in full sentences. Well-developed and appears his stated age. No facial droop or slurred speech.
Skin –Warm and dry, poor turgor, no jaundice.
Nails – No clubbing, capillary refill <2 seconds on fingers and toes.
HEENT – Normocephalic, atraumatic, external ears normal, no periorbital edema, anicteric, conjunctivae pink, EOMI, no nystagmus, oral mucosae moist.
Neck – Supple, no lymphadenopathy.
Chest – Symmetrical, no deformities. Respirations unlabored. Non-tender to palpation throughout.
Lungs– Clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Heart -RRR, no murmurs, click or rubs.
Abdomen –Soft, NT/ND, BS present, no hepatosplenomegaly, no CVA tenderness.
Musculoskeletal –FROM of all joints. No swelling or tenderness.
Neurologic –
Awake, alert and follows commands, no aphasia.
CN: PERRL, EOMI, full visual field. No facial asymmetry noted. Facial sensation equal. Normal gag reflex. SCM/Trap strength 5/5. Tongue is midline on protrusion.
Motor: normal bulk and tone. Fine finger movements equal bilaterally. No tremors. Strength 5/5 in all extremities.
Sensory: intact and symmetrical throughout.
Coordination: No dysmetria
Gait: Steady gait, able to tandem walk. Romberg negative.
Peripheral Vascular – Pulses are 2+ bilaterally in upper and lower extremities.
Labs and imaging:
- WBC: 5.71
- Hemoglobin: 14.8
- Hematocrit: 42.4
- Na: 139
- K: 5.1
- Cl: 104
- CO2: 25
- BUN: 17.2
- Creatinine: 1.13
- Glucose: 120
- Ca: 9.1
- Anoin gap: 10
- PT: 10.4
- APTT: 26.6
- INR: 0.91
- LFT: WNL
- TSH: 1.940
- Free thyroxine: 1.050
- Troponin: <0.01
- CT Head w/o contrast:
- No acute intracranial hemorrhage or evolving large vessel territorial infarct. Nonspecific white matter findings most commonly seen in the setting of chronic microvascular ischemic disease.
- CT Angiography Head and Neck with and without IV Contrast:
- No evidence for large vessel occlusion
- Moderate bilateral calcific plaque in the cavernous carotid segments. Unremarkable CTA of the cervical arterial vasculature.
DDx:
- Transient ischemic attack
- Stroke
- Brain tumor
Assessment and Plan:
63-year-old male with PMH of HTN, HLD, CAD s/p 3 Stents presenting due to episode of expressive aphasia. Patient was at his doctor’s office around 2 PM today and noticed that he had trouble speaking. Aphasia resolved on its own 30 minutes later. Per patient, his last known normal was 1:30PM. In ED, neurological exam was unremarkable. Admitted to Medicine for Stroke Rule Out.
#Rule Out Acute Stroke
– NIH SS =0
– Patient was not a TPA candidate as he is currently with NIH SS = 0, no neuro focal deficits at this time. Also presented outside of timeframe for TPA (symptom onset > 4.5 hours prior to arrival).
– CTA Head and Neck with no large vessel occlusion
– ABCD2 score: 1 (age > 60), 1 (BP > 140/60), 1 (speech impairment w/o weakness), 1 (duration of symptoms between 11 to 59 minutes) = 4 points moderate risk
– Admit to stroke unit for further w/up w/Q4hrs neuro and vital sign checks.
– Neurology consulted, recommend follow up MRI Brain w/o contrast
– Monitor on Telemetry Unit
– Follow up A1c, Lipid Profile, B12, Folate, Homocysteine
– Start ASA 81 daily, Plavix 75 mg daily
– Increase home Lipitor to 80 mg qhs
– Allow for permissive hypertension until MRI of brain. Hold all anti-hypertensives medications if SBP <180 and DBP <110.
– Fluid boluses PRN to avoid lowering BP greater than 15% in the first 24 hours
– Follow up PT/OT Recommendation
#HTN
– Not taking any BP meds at home
– Allow for Permissive HTN, Hold Antihypertensive Meds
– Fluid boluses PRN to avoid lowering BP greater than 15% in the first 24 hours
#HLD
– Follow up Fasting Lipid Profile
– Increase home Lipitor to 80 mg qhs
#CAD S/p 3 Stents
– Last Stress test in 7/2019: No Perfusion Abnormalities
– TTE in 2020 with normal EF
– Follow up with outpatient Cardiologist
GI ppx: Not needed
DVT PPX: Lovenox SQ
Patient education:
The priority right now is to rule out stroke. Stroke happens when one part of your brain didn’t get enough blood supply. It can be caused by a blockage in the blood vessel, or rupture of the blood vessel in the brain. Stroke could cause expressive aphasia, which is having troubling expressing the words. However, stroke usually have other symptoms such as facial droop and weakness in one side of your body. If you ever develop these symptoms, call 911 immediately. You don’t have these typical stroke symptoms, and your CT scan of the head did not show bleeding in your brain or large vessel occlusion. It’s less likely that you had an acute stroke. Since your symptoms resolved on its own and you don’t have any neurological symptoms right now, its likely that you had a transient ischemic attack, or a mini-stroke. It happens when a blood vessel in your brain was block for a short period of time. However, we still want to admit you for observation and for an MRI of the brain. MRI is more sensitive. It can show us if there is any blockage even in the small vessels in the brain.
