General Data

NAME:

AGE:

GENDER:

ADDRESS:

DATE OF BIRTH:

PLACE OF BIRTH: C

OCCUPATION:

CIVIL STATUS:

RELIGION:

ATTENDING PHYSICIAN:

DATE ADMITTED:

TIME ADMITTED :

ADMITTING INSTITUTION:

CC:
Increased weakness and slurred speech

HPI:
The patient is a 61 yo gentleman with CVA in September 2010, hypertension, hyperlipidemia, type 2
diabetes, seizure d/o, and cocaine abuse who presents with increased global weakness, slurred
speech, and altered mental status. At approximately 4:00 AM, the patient was found by wife sitting
on the couch, unable to stand up, respond appropriately to questioning, or speak clearly. The room
was in disarray, possibly indicating a fall of some kind, and there was also evidence of urinary
incontinence with a wet area on the couch. On presentation to the ED, the patient was found to
have right upper and lower extremity weakness, slurred speech, and disorientation. The patient was
unable to explain most of the night’s events but did state that he fell on his buttocks. He also
thought he was speaking funny despite knowing what he wanted to say. Although patient did have
some residual right sided weakness from the previous stroke that requires the use of a cane, wife
noted that this episode was markedly worse in terms of lower extremity strength and ambulation.
Patient endorses significant cocaine use and noncompliance with medications since May 2006.
When seen in ED at 5:00 pm, patient at baseline per wife. Patient denies head trauma, headache,
change in vision, nausea, and vomiting. No dizziness, SOB, chest pain, or palpitations. Patient denied
urinary incontinence despite evidence described above.

PMHx:
 CVA: September 2010
o MRI w/ and w/o contrast: acute lacunar strokes in anterior basal ganglia and internal capsule on
left and in the left central pons; nonspecific small area of enhancement in right basal ganglia possibly
from subacute strokes; old encephalomalacic changes in both frontal lobes.
o Bilateral carotid u/s: negative study – no atherosclerotic plaque seen in either bifurcation region
o On d/c, started on baby aspirin x 2 per day; discontinued by patient
 HTN: Long standing h/o uncontrolled hypertension, currently untreated
 Hyperlipidemia: last fasting lipid panel in 1/06; total cholesterol at 178, triglycerides at 127, HDL
at 42, LDL at 111; now untreated due to medication noncompliance. Current guidelines of ATP III
place goal LDL at <100 with DM as CHD equivalent risk factor and optimally less than 70.
 DM type 2: diet controlled. Last HbA1c in 1/06 at 5.6. No known
neuropathy/retinopathy/nephropathy. No previous labs seen for urinary microalbumin, last
ophthalmology appt “a while ago”.
 Seizure d/o:
o Diagnosed 2001 as tonic-clonic seizure with postictal state lasting approx 45 min. Suspected
posttraumatic etiology, although cocaine abuse could have contributed.
o Last seizure per wife approx 3 years ago. Currently not on antiepileptic medications.

o Previous EEG done at initial presentation of seizure event demonstrated some right
frontotemporal slowing and spiked discharges.
 H/o MVA as child with subsequent frontal lobe injury

FHx:
 Mother: alive and well
 Father died in late 60s of cancer, unknown type
 Otherwise FHx unknown, no relationship with rest of family

PE:
 Vitals:
o T = 97.0 (oral)
o P = 90
o RR = 18
o % sat = 96% (RA)
o BP = 197/104
 General: Patient is an overweight man in NAD, lying comfortably in bed.
 Eyes: PERRL. EOMI. Sclera clear. Mild right sided ptosis.
 ENT: Nares without any discharge. Mucous membranes moist. Oropharynx without erythema or
exudate. Cerumen obstructing view of TMs bilaterally.
 Neck: Neck supple, trachea midline. No thyromegaly. No carotid bruits. Pulses 2+ bilaterally.
 Lymph Nodes: No lymphadenopathy (cervical, axillary, and inguinal)
 Cardiovascular: RRR, Normal S1, S2; no murmurs, rubs, or gallops; no prominent neck veins or
JVD noted. 2+ pulses bilaterally (radial, femoral, dorsalis pedis)
 Lungs: Chest wall motion symmetric with no accessory muscle use. Resonant to percussion. CTA
bilaterally. No wheezes, rhonchi heard.
 Skin: Warm to touch; no rashes/scars; dry skin noted on lower legs bilaterally.
 Abdomen: Soft, nontender, nondistended with active bowel sounds. Liver width at 10 cm to
percussion along midclavicular line, nonpalpable. Rectal exam deferred due to lack of GI or prostatic
associated complaints, no s/sx of overt or occult bleeding, no complaints of
numbness/tingling/paresthesias. Will perform if heparin gtt needed.
 Extremities: No cyanosis, clubbing, or edema.
 Musculoskeletal: Normal ROM throughout. Contractures of right hand, with resistance to manual
spreading/straightening of fingers. No joint swelling or tenderness noted.
 Neurological:
o Alert and oriented to person, place (“hospital”, not CMC), time (11/28/2006), and situation
(“possible stroke”).
o Slowed mentation and responded with limited speech.
o No dysarthria, no dysphasia.
o CN II-XII grossly intact. Face symmetric with no mouth droop.
o 4/5 strength in right deltoid, biceps, triceps, hip flexor, quadriceps, anterior tibialis,
gastrocnemius. 5/5 strength in left. Grip strength equal bilaterally. Normal tone and bulk bilaterally.
o Cerebellar function with finger-to-nose and shin-heel testing normal. Mild right side intention
tremor. Rapid alternating movements minimally slowed.
o Sensation to light touch slightly decreased bilaterally on ankles.

o Gait with mild right foot drag. Negative Romberg.