Emergency Department
Patient Case Number: ED17-Wasserman, Jerome
Patient Name: Jerome Wasserman | DOB: 12-15-62 | Sex: M
Date of Service: 04-22-XX | Attending Physician: Mark Sterling, MD
Reason for Visit: Numbness in extremity

# Chief Complaint: Numbness in extremity

# History of Present Illness:

Jerome Wasserman presents to the Emergency Department complaining of numbness. He has a PMHx significant for htn and dyslipidemia and family hx significant for his brother who had a CVA ten years ago. At a presentation this evening from approximately 5-5:30pm the pt felt tingling and numbness from the middle of his face to the left side of his head. Pt reports that currently the left side of his face and left arm are weak and numb. Pt reports dull pain in his left bicep and pain directly from his heart which has since dissipated. Pt notes chewing four baby aspirin after the incident. Pt notes taking his blood pressure medications today. Pt reports that he had some chest discomfort for less than a minute on the way to the ED. Pt denies any leg numbness, inability to swallow or speak, blurry vision, or tongue numbness. Patient is right-handed. There are no further complaints at this time.

# Medical History: Htn, anxiety, allergic rhinitis, dyslipidemia, GERD, DDD (lumbar)

# Surgical History: Clavicle dislocation repair

# Medications: Atenolol, Alprazolam, Carvedilol, Omeprazole, Tylenol #3

# Vitals:

Blood Pressure | 180/100
Pulse | 88
Resp. | 18
Temp | 97.8°F
Temp source | Oral
SpO2 | 97% O2

O2 via | Room Air
Weight | 290lbs
Height | 6’0 ft
Level of Pain | 5/10

# REVIEW OF SYSTEMS:

See HPI for pertinent positives and negatives. All other ROS reviewed and negative.

# Physical Examination

# GENERAL: Awake, alert, oriented, no distress

# HEAD: Normocephalic, Atraumatic, left sided facial droop

# EYE: PERRL, EOM’s intact EAR: External ears normal NOSE: Nares clear

# OROPHARYNX: Oropharynx clear, mucus membranes moist and lips, buccal mucosa, and tongue normal

# CHEST: Normal, non-tender

# LUNGS: Clear and equal bilaterally

# HEART: Regular rhythm, no murmurs appreciable, S1 normal, S2 normal

# ABDOMEN: Abdomen soft, non-tender

# SKIN: Normal, warm, dry

# UPPER EXTREMITIES: Strength grip is 5/5, 4+/5 proximal and distal, upper 5/5 bilaterally, DTR 1 /4 equal and symmetric, sensory loss to left arm compared to right, good distal pulses

# LOWER EXTREMITIES: RLE proximal and distal muscle strength 5/5, right proximal distal and plantar distal muscle strength 5/5, left is about the same 4+/5, gross sensory loss of left, DTR ¼ equal and symmetric, good distal pulses.

# NEURO: Facial droop on left side, normal speech, mild abnormal finger to nose on left, as compared to right, subtle left leg numbness, Babinski absent bilaterally, mild tongue deviation to the right

# NIH Stroke Scale

1 a. Level of Consciousness: alert = 0

1 b. LOC Questions: (month, age): both correct= 0

1 c. LOC Commands (open and close eyes, make fist and let go using non-paretic hand): obeys both correctly =.

1. Best Gaze (eyes open and patient follows examiner’s finger or face): normal = 0

2. Visual (visual threat or finger counting in each quadrant): no loss = 0

3. Facial Palsy (show teeth, raise eye brows and squeeze eyes shut, or grimace symmetry in a comatose patient): minor asymmetry (flattened nasolabial fold, asymmetry on smiling) = 1

5a. Motor Arm (extend arm (palms down) to 90 degrees and score drift/movement (10 seconds) -Left: no drift = 0

5b. Motor Arm: (extend arm (palms down) to 90 degrees and score drift/movement (10 seconds)- Right: no drift = 0

6a. Motor Leg (elevate leg 30 degrees and score drift/ movement (5 seconds) - Left: no drift= 0

6b. Motor Leg (elevate leg 30 degrees and score drift/ movement (5 seconds) - Right: no drift= 0

1. Limb Ataxia (finger to nose, heel down shin): present in one limb= 1

2. Sensory (pin prick to face, arm, trunk and leg, compare side to side): dense loss (complete loss of sensation) = 2

3. Best Language: no aphasia = 0

4. Dysarthria (evaluate speech clarity by patient repeating listed words): normal articulation = 0

5. Extinction and Inattention: no neglect= 0

# Total: 4

# TPA decision: no tpa as pt has hemorrhagic bleed

# ED Course

The patient was seen and examined in the ED by the treating provider(s). The following Alert was initiated: Stroke Alert

Based on the history and physical exam the following differential diagnosis was formulated and includes but is not limited to: Stroke, TIA, intracranial hemorrhage.

Test | Value | Ref Range
COLOR, UA | Straw | YEL
CLARITY, UA | Clear | Clear
GLUCOSE, UA | Negative | Neg mg/dL
BILIRUBIN, UA | Negative | NEG
KETONE, UA | Negative | Neg mg/dL
SPECIFIC GRAVITY | 1.008 | 1.003-1.030

# The following diagnostic studies were performed and reviewed: Routine Urinalysis

BLOOD, UA | Negative | NEG
PH, UA | 7.0 | 5.0-7.5 units
PROTEIN, UA | Negative | Neg mg/dL
UROBILINOGEN, UA | Normal | Norm mg/dL
NITRITE, UA | Negative | Neg
ESTERASE, UA | Negative | Neg

COMMENT, UA Screen Negative-Microscopic not done

# APTT

Test | Value | Ref Range
APTT-Patient | 26 | 21-38 seconds
CBC/DIFF |  |
Test | Value | Ref Range
WBC | 8.96 | 4.00-10.80 K/µL
RBC | 5.18 | 4.50-5.25 M/µl
HGB | 15.6 | 14.0-16.8 g/dL
HCT | 48.3 | 40.0-48.4%
MCV | 93.2 | 82.0-99.5 fL
MCH | 30.1 | 27.0-34.0 pg
MCHC | 32.3 | 32.0-36.0 g/dL
RDW | 14.6 | 11.5-15.5%
PLATELET COUNT | 208 | 140-400 K/µL
MPV | 9.1 | 6.6-11.1 fL
NEUTS | 57.7 | 40-75%
LYMPHS | 32.3 | 18-42%
MONOS | 8.3 | 1-11%
EOS | 1.0 | 0-6%
BASOS | 0.1 | 0-2%
IMMATURE GRANULOCYTE | 0.6 | 0-2%
ABS.NEUTS | 5.18 | 1.8-7.7 K/µL
ABS. LYMPHS | 2.89 | 1.0-4.8 K/µL
ABS. MONOS | 0.74 | 0.0-1.1 K/µL
ABS. EOS | 0.09 | 0.0-0.7 K/µL
ABS. BASOS | 0.01 | 0.0-0.2 K/µL
ABSOLUTE IMMATURE | 0.05 | 0.0-0.2 K/µL

GRANULOCYTES

Basic Metabolic Panel, BMP Test | Value | Ref Range
BUN | 13 | 6-20 mg/dL
CREATININE | 0.7 | 0.6-1.2 mg/dL
SODIUM | 140 | 135-146 mmol/L
POTASSIUM | 4.2 | 3.5-5.1 mmol/L
CHLORIDE | 101 | 98-107 mmol/L
CO2 | 26 | 22-32 mmol/L
ANION GAP | 13 | 7-15 mmol/L
GLUCOSE | 93 | 70-120 mg/dL
CALCIUM | 9.3 | 8.4-10.2 mg/dL
E GLOM FILTRATE | >60.0 | >60
PT/INR |  |
Test | Value | Ref Range
PT/INR-PT | 12.7 | 11.5-14.6 seconds
PT/INR-INR | 0.93 | 0.82-1.12
Chem 8 |  |
Test | Value | Ref Range
SODIUM ISTAT | 141 | 135-146 mmol/L
POTASSIUM ISTAT | 4.0 | 3.5-5.0 mmol/L
CHLORIDE ISTAT | 104 | 100-111 mmol/L
CALCUIM, IONIZD ISTAT | 1.12 (L) | 1.13-1.32 mmol/L
CO2 ISTAT | 23 | 22-32 mmol/L
GLUCOSE ISTAT | 92 | 70-120 mg/dL
BUN ISTAT | 15 | 10-20 mg/dL
CREATININE ISTAT | 0.7 | 0.7-1.3 mg/dL
HEMATOCRIT ISTAT | 51 (H) | 40-47%
HEMOGLOBIN ISTAT | 17.3 (H) | 13.7-16.5 g/dL
ANION GAP POS ISTAT | 19 | 10-20 mmol/L
Troponin |  |

Test | Value | Ref Range
Troponin T | <0.010 | <0.100 ng/mL
CK Test | Value | Ref Range
CK | 153 | 39-308 U/L
MB Fraction of CK Test | Value | Ref Range
MB Fraction | 2.9 | 0-7.7 ng/mL

# EKG

My interpretation of 12 lead EKG preformed during this ED visit is as follows: Indication: Numbness

Rhythm: Sinus Rhythm at Rate: 65 bpm, Findings: Normal Axis, No acute ischemia. Impression: No Acute ischemia

# Chest X-ray-AP or PA and Lateral Findings

# Catheters: None.

# Tubes: None.

# Foreign bodies: No radiopaque foreign bodies are identified.

There has been interval improvement of patchy airspace disease. Lungs are clear with normal vascularity. No pleural effusion. No pneumothorax. Mild cardiomegaly.

Osseous structures are atraumatic. The imaged upper abdomen is unremarkable.

# IMPRESSION

1. No acute cardiopulmonary process on plain film examination.

# **Authenticated by Norman Antron, MD**

# CT-Head/Brain w/o Contrast

# History: Stroke Alert-left facial and arm numbness

# Technique:

Multiple helical images are obtained from the skull base to the vertex without contrast. Coronal and sagittal reformats are provided.

# FINDINGS

A new, 5 mm focus of abnormal hyperdensity has developed within the right thalamus, most compatible with acute intraparenchymal hemorrhage. No significant mass effect or surrounding edema is noted. There is mild, age related global cerebral volume loss and proportionate sulcal prominence. Patchy and confluent areas of hypodensity are noted in the bilateral periventricular and subcortical white matter, most compatible with chronic microvascular ischemic disease. Gray-white matter differentiation is otherwise grossly preserved, with no new wedge-shaped territorial infarcts. Posterior fossa structures are grossly unremarkable, and the basilar cisterns are patent. Intracranial atherosclerotic vascular calcifications are again seen. The imaged bilateral paranasal sinuses and mastoids are well aerated. Bony calvarium is intact.

# IMPRESSION

1. New, 5 mm focus of acute intraparenchymal hemorrhage in the right thalamus likely accounts for the patient’s symptoms. This location favors a

   hypertensive etiology.

2. No associated brain edema or significant mass effect.

3. Mild cerebral atrophy with chronic deep white matter ischemic changes and intracranial atherosclerosis.

# **Authenticated by: Norman Antron, MD** CRITICAL CARE TIME

I have provided 45 minutes of critical care to this patient. The critical care time was

independent of procedures performed by me. This time includes time spent at bedside in direct patient care, medical records review, discussions with patient and family, consultations, documentation, and other patient care activities - including medical management and medical decision making. This time is above and independent of any time spent on separately billable procedures.

# MDM

This patient presents to the emergency room today as he noted an acute onset of left sided arm and facial numbness with left arm weakness thus prompting his ER

visit this evening. Patient was made a stroke alert upon arrival and found to have a small area of intraparenchymal hemorrhage of the right thalamus consistent with a hemorrhagic stroke. The patient was not a tPA candidate due to bleeding. Patient had no change or decline in his neurologic or symptomatic status while in the ER and was started on a Cardene drip for appropriate blood pressure control. Case was discussed with the on-call stroke neurologist as the transfer center was called to discuss the case. Patient was seen by Neurosurgery without any recommendations for surgical intervention and the placement was placed in the intensive care unit for close monitoring and blood pressure management. The CT imaging was most consistent with hypertensive bleed. Prior to arrival the patient had taken 4 to 5 baby aspirin but there was no recommendation for any medications to use for any reversal by Neurology, critical care, neurosurgery, or clinical pharmacy. I went over all the test results with the patient as well as his wife and show them the CT imaging of the bleeding. The patient is wife were very pleased with her care and demonstrated understanding a being admitted to the hospital and treatment plan.

# Final Diagnoses

1. Hemorrhagic cerebrovascular accident (CVA)

2. Hypertensive emergency

3. Hyperlipidemia

4. GERD.

5. Anxiety

6. Allergic rhinitis

7. DDD lumbar.

8. Facial weakness and hemiplegia, left.

# DISPOSITION:

Admitted to inpatient critical care. The patient’s final disposition, review of diagnostics, treatments, differential diagnoses excluded and the provisional diagnosis suspected were reviewed with the patient and/or any family members present.

Questions were solicited and answered to satisfaction if presented.

# Electronically Signed By: Mark Sterling, MD

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