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Saint Mungo's Hospital

Hospitalist Progress Note

Acute Care Setting (Setting 1)

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NAME: James Krum 

MRN: H07311980

AGE: 64 year old               DOB: 12/25/1960

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SUBJECTIVE:

Patient seen at bedside. Code stroke was called yesterday afternoon as nursing staff noted that the patient was having worsening left-sided weakness. The patient was unable to grip with his left hand when he was able to earlier in the day, and he was requiring increased assistance to stand. Acute stroke protocol was carried out, and additional imaging was completed.

 

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OBJECTIVE:

Vitals

  • Blood pressure: 141/82 mmHg

  • Heart rate: 84 bpm

  • Respirations: 27 breaths/minute

  • Temperature: 97.8 degrees oral

  • SpO2: 95%

 

Review of Systems

  • CONSTITUTIONAL: Weight has been stable; no fevers or night sweats.

  • EYES: No visual complaints.

  • HENT;  No nasal congestion, or sore throat.  Hearing is intact.

  • CARDIOVASCULAR: Denies lower extremity edema, palpitations, exertional chest pain or pressure, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, claudication, and syncope

  • RESPIRATORY:  No cough, wheezing, or shortness of breath.

  • GASTROINTESTINAL: No nausea, vomiting, heartburn, abdominal pain, diarrhea, constipation or blood.

  • GENITOURINARY: No hematuria, dysuria, urgency, frequency and nocturia.

  • MUSCULOSKELETAL: No musculoskeletal pain, weakness, or stiffness.

  • INTEGUMENT: No rashes, change in any skin lesion, or pruritus.   No breast changes.

  • NEUROLOGIC: Left-sided inattention and upper greater than lower extremity weakness

  • PSYCHIATRIC: Sleeping well; denies depression or anxiety.

  • ENDOCRINE: Denies polyuria and polydipsia; denies fatigue and hot or cold intolerance.

 

Labs – gathered 10/4/24 at 0410

  • WBC: 5.1

  • HGB: 15.8

  • HCT: 44.9

  • PLTC: 190

  • MCV: 85.2

  • NA: 140

  • K: 4.1

  • CL: 104

  • TCO2: 22

  • BUN: 22

  • CRE: 0.77

  • GLU: 183

  • CA: 8.8

  • ALB: 4.2

  • TBIL: 0.5

  • ALP: 85

  • GOT: 23

  • GPT: 30

 

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ASSESSMENT/PLAN:

Acute CVA in the right middle cerebral artery territory 

  • Head CT from 10/2 shows non-specific white matter change and cerebral atrophy with findings in the right corona radiata most likely related to progressive vascular disease, generalized atrophy with prominence of the ventricles and sulci noted. CTA angio of neck from 10/2 indicated total volume ischemia in the right middle cerebral artery territory, no vascular stenosis or occlusion noted. No aneurysm or vascular malformation identified. Unremarkable CTA of the head. MRI head without contrast on 10/3 demonstrated small foci of acute/subacute ischemic injury within the right middle cerebral vascular territory. No hemorrhagic conversion noted, no hydrocephalus, intracranial blood products, or intracranial mass noted. Neurology consulted and raised suspicion for an embolic origin of the multiple right middle cerebral artery strokes. TTE on 10/3 was unremarkable without embolic source noted and neurology recommended a TEE for further follow up, which was also normal without intracardiac emboli. 

  • Patient experienced increased left-sided weakness and a code stroke was called yesterday, 10/3. Repeat CT of head without contrast was not significant for any acute hemorrhage. MRA of head and neck revealed an increase in the multiple small scattered areas of acute/subacute ischemic infarcts within the right middle cerebral artery vascular territory, as well as a new occlusion of the superior division branch of the right middle cerebral artery with new high-grade narrowing of the inferior division of the right middle cerebral artery. Consult placed to Interventional Neuroradiology - patient not a candidate for neurointervention due to the apparent total/near total right middle cerebral artery occlusion; patient would not have any real benefit to be gained from intervention.

  • Neurology recommends to continue with current management, including Aspirin and Plavix. Lipid panel normal. Allow permissive hypertension with systolic blood pressure to be maintained between 120-200. 

  • Continue with physical, occupational, and speech therapy. Occupational therapy evaluated yesterday, physical and speech therapy to evaluate today. Patient to be evaluated by Physical Medicine and Rehabilitation to determine appropriateness for discharge to inpatient rehabilitation. Case manager also following. 

 

Electronically signed by Remus Dursley, MD 10/4/2024 

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