Medical Specialty:
Consult - History and Phy.

Sample Name: Gen Med Consult - 7

Description: Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Right-sided facial droop and right-sided weakness.

HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation. While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop. The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.


SOCIAL HISTORY: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.

FAMILY HISTORY: Noncontributory.

1. Cerebrovascular accident with expressive aphasia and lower extremity weakness.
2. Abnormality of gait and wheelchair bound secondary to #1.
3. Hypertension.
4. Chronic obstructive pulmonary disease, on nasal oxygen.
5. Anxiety disorder.
6. Dementia.

PAST SURGICAL HISTORY: Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.

REVIEW OF SYSTEMS: Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.

GENERAL: She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.
VITAL SIGNS: Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.
HEENT: Pupils are equal, round, and reactive to light. External ocular muscles are intact. Conjunctivae anicteric. There is a slight right-sided facial droop. Oropharynx is clear with the missing teeth on the upper and the lower part. Tympanic membranes are clear.
NECK: Supple. There is no carotid bruit. No cervical adenopathy.
CARDIAC: Regular rate and rhythm with 2/6 systolic murmur, more at the apex.
LUNGS: Clear to auscultation.
ABDOMEN: Soft and no tenderness. Bowel sound is present.
EXTREMITIES: There is no pedal edema. Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.
NEUROLOGIC: There is right-sided slight facial droop. She moves both upper extremities equally. She has withdrawal of both lower extremities by touching her sole of the feet.
SKIN: There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.

LABORATORY DATA: The CT scan of the head shows brain atrophy with no acute events. Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92. Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000. The urinalysis was more than 100 white blood cells and 10-25 red blood cells. Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.

1. Recent cerebrovascular accident with right-sided weakness.
2. Hypertension.
3. Dementia.
4. Anxiety.
5. Urinary tract infection.
6. Abnormality of gait secondary to lower extremity weakness.

PLAN: We will keep the patient NPO until a swallowing evaluation was done. We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170. Neuro check every 4 hours for 24 hours. We will start her on amikacin IV per pharmacy. We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done. Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n. I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.

Keywords: consult - history and phy., hypertension, right-sided weakness, facial droop, wheelchair bound, blood pressure, swallowing evaluation, cerebrovascular accident, weakness,