Medical Specialty:
General Medicine

Sample Name: H&P - Weakness

Description: Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Right-sided weakness.

HISTORY OF PRESENT ILLNESS: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.


MEDICATIONS: Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d., Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d., insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation.

PAST MEDICAL HISTORY: Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).

SOCIAL HISTORY: The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs.

FAMILY HISTORY: Negative for cerebrovascular accident or cardiac disease.

REVIEW OF SYSTEMS: As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection.

VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air.
GENERAL: This is a pleasant elderly female who appears stated age, in mild distress.
HEENT: Oropharynx is dry.
NECK: Supple with no jugular venous distention or thyromegaly.
RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles.
CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids.
ABDOMEN: Soft. Normal bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations.
NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia.
VASCULAR: The patient has good capillary refill in her fingertips.

LABORATORY DATA: BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely.

1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient.
2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed.
3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics.
4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control.
5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels.

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