Date of Admission: [DATE]. Service Provided: History and ...

1 date of Service : ___ [ date ]. date of Admission: ___ [ date ]. Service Provided: History and Physical Chief Complaint: Weakness and midepigastric pain. History of Present Illness: This is a 64-year-old Cambodian male who presents with weakness for 2 days. The patient speaks Cambodian mainly, and most of the History is taken from the son who is not a good historian. Apparently, the patient had acute onset of left-sided weakness in his arm and leg that started 2 days prior to admission with associated mild bifrontal headache. He denies double vision, incontinence, or seizures. He does note that he has mild imbalance as well as dizziness, and he also has decreased left-sided sensation.

2 The patient has been unable to get up and walk on his own as a result of this and needs assistance with ambulation. The patient also complains of nausea and vomiting about 1 hour post meals, and this has been going on for approximately 1 to 2 years, occurs approximately 2 to 3 times a day. It is associated with midepigastric pain that increases with meals and decreases with activity. He also admits the mild shortness of breath limiting him to approximately 1 block. Denies hematochezia or hematemesis. Reports some weight loss, unquantified, and does report melena daily. Review of Systems: As per HPI. Otherwise, 10-point review of systems was negative. Past Medical History 1.

3 Hypertension. 2. Coronary artery disease, after which 2 to 3 years ago he was diagnosed with an MI, status post catheterization "cleaned out arteries" in ___ [PLACE] versus ___ [PLACE]. 3. Hyperlipidemia. Past Surgical History : Denies. Family History : Negative for heart disease, cancer, or diabetes. Social History : The patient smokes tobacco 1 pack per day for 20 years. Denies alcohol or IV drug use. Lives with 3 sons and his wife. Moved from ___ [PLACE] approximately 20 years ago. Speaks little English, but is able to have a conversation. Usually cares for self completely, but over the past two days has needed assistance. Medications: Nexium 40 daily, Diovan 320/25 daily, Norvasc 10 daily, labetalol 300 daily, Plavix 75 daily, and Crestor 40 daily.

4 Crestor maybe 10 mg daily, this was unclear based on son's History . Allergies: No known drug allergies. Physical Examination Vital Signs: Temperature 37, pulse 74, respiratory 14, and blood pressure 173/89. General: Alert and responsive to commands. Oriented x3. HEENT: Mucous membranes moist. Pupils equally round and reactive to light. Extraocular movements intact. Decreased facial sensation on the left side. No bruits. No lymphadenopathy. CVS: Regular rate and rhythm. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi. Cranial nerves 2 through 12 grossly intact, otherwise. Rectal: Hard stool, OB negative.

5 Labs: White blood cells , hemoglobin , hematocrit , platelets 278, MCV , neutrophils 82%, and lymphocytes 14%. PT , INR , and PTT 25. Sodium 141, potassium 3, chloride 106, bicarbonate 26, BUN 19, creatinine , glucose 122, and calcium 9. Total protein , albumin , alkaline phosphatase 57, total bilirubin , AST 17, and ALT 19. CK 89, MB , and troponin less than Imaging: Chest x-ray negative for acute cardiopulmonary disease. CT head, remote left basal ganglia lacunar infarct. EKG; T-wave inversions in leads II, III and aVF as well as V5 to V6. Assessment and Plan: A 64-year-old Cambodian male with History of hypertension, hyperlipidemia, and coronary artery disease presenting with 2 days of left-sided weakness and decreased sensation as well as 1- to 2-year History of midepigastric pain.

6 1. Left-sided weakness for 2 days. The patient has History of stroke given CT head finding. No acute changes on CT of the head at this time. However, given his History , plan will be to MRI, MRA, echocardiogram to rule out thrombus, or congestive heart failure. We will start aspirin and continue the patient's Plavix and Crestor and ordered PT and OT for the patient. 2. Midepigastric pain. This could be anginal equivalent versus gastritis versus ulcer versus malignancy given the patient's recent weight loss. The patient was OB negative. We will consider EGD and colonoscopy as an outpatient given chronic History . We will obtain cardiac enzymes h. to rule out acute coronary syndrome, so far 2 sets negative.

7 We will start beta blocker, metoprolol mg , and hold the patient's labetalol that he takes as an outpatient. Continue aspirin, followup echocardiogram, and start Maalox and Protonix. 3. Coronary artery disease. For now, we will continue aspirin, Plavix, statin, beta blocker, and ARB, and followup cardiac enzymes, echocardiogram, and fasting lipid panel. 4. Hypertension. Restart home medications except use metoprolol rather than atenolol. Possible infarct occurred greater than 24 hours ago, so it will be okay to restart the patient's home medications at this time. 5. Hyperlipidemia. Restart Crestor 10 mg nightly. Followup lipid panel. 6. Fluids, electrolytes, nutrition/Gastroenterology: For now, keep patient NPO, advance diet in if tolerates.

8 Prophylaxis sequential compression devices. Referring Physician: ___ [NAME]. date of Consultation: ___ [ date ]. Service Provided: Neurology Consultation Chief Complaint: Evaluation of possible neurosyphilis. Reason for Consultation: Mr. ___ [NAME] is a 64-year-old right-handed Cambodian man with somewhat poor English, somewhat uncooperative, states that he has told several doctors per History and refuses to provide any further information. The patient apparently has complained of abdominal pain and along with chest pain there might have been some headache in association and had been admitted to medicine Service . The patient states that he also had been dizzy for couple days, denies any nausea or vomiting but seems to say there are some occipital headache.

9 The patient is admitted to medicine Service and because of overall poor History , several evaluations are done and serum test is positive for RPR, subsequently has a treponemal TP-PA from serum is also positive. Because of as this possibility of neurosyphilis is being considered, neurology has been asked to evaluate the patient. The patient subsequently because of a History of vertigo and unsteadiness, the patient also underwent MRI scan, was said to be abnormal in addition. The patient has remained clinically stable, is undergoing evaluation for possible abdominal pain. Past Medical History : The patient refuses to divulge any significant medical problems in ___ [PLACE] and avoids question regarding possible sexual practices.

10 Social History : The patient has been in United States for approximately 20 years, further History is difficult to obtain because of poor cooperation. Does smoke cigarettes, no IVDA in the background. The patient states that he is married, is waiting for his son to arrive to the hospital. Review of Systems: Unremarkable. Physical Examination Vital Signs: Temperature is , blood pressure is 140/70, pulse of 75. General Examination: The patient looks comfortable, is awake, alert with mild irritative behavior, and states that he wants to be left alone. Neck: Without any obvious stiffness. Chest: Distant breath sounds. Cardiac: Negative murmur. Abdomen: Examination without any rebound, does not cooperate to allow for full examination.