Emergency Department
Patient Case Number: ED28-Fray, Scott
Patient Name: Scott Fray | DOB: 09-21-60 | Sex: M
Date of Service: 08-11-XX | Attending Physician: Derek Hahn, MD
Reason for Visit: Stroke-like symptoms

# History of Present Illness:

This patient presents to the Emergency Room with complaints of worsening stroke-like symptoms that started this morning. The history is limited secondary to the patient’s expressive aphasia. The patient’s wife states that the patient did not seem right when he woke up this morning around 8am because he was unable to speak. She then noticed that the patient was starting to get a right-sided facial droop so she brought him into the ED. She adds that his symptoms have gotten worse since this morning. Currently, the patient expresses that he has a headache. Pt denies chest pain, breathing difficulties, abdominal pain, or other complaints. He is diabetic and has a stent in his heart. His wife states that he has a family history of strokes.

# Source of History: patient and patient’s wife History Limited By: aphasia (expressive) Position: head

# Timing: worsening

# Associated Symptoms: + headache

# Note: expressive aphasia, right-sided facial droop

# Medical History: CAD, htn, Dyslipidemia, diabetic ulcer, neuropathy, PVD

# Family History: DM, Stroke

# Review of Systems

See HPI for pertinent positives and negatives. A total of ten systems were reviewed and were otherwise negative.

# Medications:

Aspirin (Aspirin 81), 81 MG PO DAILY Atenolol (Tenormin), 50 MG PO BID Celecoxib (Celebrex), 100 MG PO DAILY

Cholecalciferol (Vitamin D), 1,000 INTER.UNIT PO DAILY Cyanocobalamin (Vitamin B-12), 100 MCG PO DAILY Ibuprofen (Ibuprofen), 600 MG PO TID

Insulin Aspart (Novolog), Unknown Dose SC AC Insulin Glargine (Lantus), 30 UNITS SC BID

Losartan Potassium (Losartan Potassium), 50 MG PO DAILY Nitroglycerin (Nitrostat), 0.4 MG UT PRN

Pantoprazole (Protonix), 40 MG PO DAILY Simvastatin (Zocor), 40 MG PO QPM Gabapentin (Neurontin) 600 MG PO DAILY Cilostozal 100 MG PO BID

# Vitals:

Temperature | 98.6°F
Pulse | 78
Respirations | 18
Blood Pressure | 178/90
SpO2 | 96% on room air

# Physical Examination:

GENERAL: Awake, alert, well appearing, no distress

HEENT: Normocephalic, atraumatic. TM's normal. Oropharynx unremarkable.

EYES: PERRL. EOMI. Normal conjunctiva. Sclera non-icteric.

NECK: Supple. No nuchal rigidity, FROM. No JVD or bruit.

RESPIRATORY: CTA

CARDIAC: RRR. No murmur.

ABDOMEN: Soft, non-distended. No tenderness to palpation. No rebound or guarding. No masses.

RECTAL: Deferred.

MUSCULOSKELETAL/Extremities: Unremarkable. No edema. No discoloration. Gross motor strength symmetric. Unable to palpate distal pulses. NEURO: Cranial nerves 2-12 grossly intact. Normal sensorium. LOP sensation in both feet. Expressive aphasia present. Right-sided facial droop. No pronator drift. SKIN: No rash or jaundice noted. Diabetic ulcer noted on RLE.

LYMPH: No adenopathy.

Radiological Examinations

Single View Chest Xray, AP Clinical History: Stroke

Findings: The examination is degraded by portable technique and patient rotation. The heart is enlarged and there is mild atherosclerotic calcification of the thoracic aorta. There is minimal left basilar atelectasis. The lungs and pleural spaces are otherwise clear. No pneumothorax is seen. The bony thorax is grossly intact.

# IMPRESSION: Cardiomegaly with no acute cardiopulmonary abnormality.

# **Authenticated by Eric Edwards, MD**

# CT of Brain w/o IV Contrast

# Clinical History: Stroke-like symptoms. Right-sided facial weakness TECHNIQUE: Unenhanced axial CT scan of the brain is performed from the vertex to the skull base. Automated dose control exposure was utilized.

# CT DOSE: 729.78 mGycm

# FINDINGS: Brain parenchyma: There is loss of gray-white matter differentiation seen in the posterior left frontal lobe consistent with acute to subacute infarct. There is mild localized mass effect with effacement of the adjacent cortical sulci. No additional foci of acute ischemia are suspected. There is no hemorrhage or midline shift. No extra-axial fluid collection is seen. Ventricles, sulci, cisterns: Normal in configuration. See above. intracranial vasculature: There is mild atherosclerotic calcification of the cavernous carotid arteries. Calvarium: Unremarkable. Sinuses and mastoids: The visualized paranasal sinuses are clear. The mastoid air cells are well pneumatized. Orbits: The bony orbits are grossly intact.

1. There is focal loss of gray-white matter differentiation in the posterior left frontal lobe consistent with acute to subacute infarct. There is localized mass effect.

2. There is no hemorrhage or midline shift. No additional foci of acute ischemia is suspected.

Findings were discussed with Dr. Hahn in the emergency department at the time of interpretation.

# Laboratory Results

Red Blood Count 5.03, Mean Corpuscular Volume 84.1, Mean Corpuscular Hemoglobin 28.6, Mean Corpuscular Hemoglobin Concentration 34.0, Mean Platelet Volume 9.5, Neutrophils (%) (Auto) 47.6, Lymphocytes (%) (Auto) 32.0, Monocytes (%) (Auto) 11.7, Eosinophils (%) (Auto) 7.6, Basophils (%) (Auto) 0.6, Neutrophils # (Auto) 4.15, Lymphocytes# (Auto) 2.79, Monocytes # (Auto) 1.02, Eosinophils # (Auto) 0.66, Basophils # (Auto) 0.05

# MDM

Etiologies such as CVA, TIA, metabolic, infection, hypo/hyperglycemia, electrolyte abnormalities, cardiac sources, intracerebral event, toxicologic, neurologic, as well as others were entertained.

The patient was evaluated upon arrival. A stroke alert was initiated. The patient was taken emergently to CT scan and he was found to have an abnormality concerning for CVA. Stroke consultation was made. I discussed the case with Dr. Preston. The patient woke up with his symptoms. Given that in conjunction with the CT finding it was felt that this was a subacute event and he would not qualify for TPA or interventional stroke treatment. Conservative management with Aspirin, Plavix, and additional imaging was recommended. The patient and family were informed. I did consult with internal medicine. The patient was given his Plavix load as recommended by neurology. The patient was hydrated with normal saline. He was admitted for further treatment regarding his CVA.

# Impression: Stroke

# Assessment:

Cerebral infarction with facial weakness.

Type 2 DM with skin ulcer and diabetic neuropathy. Diabetic peripheral angiopathy.

Hypertension Hyperlipidemia ASHD, no angina.

# Electronically Signed By: Derek Hahn, MD

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