RESULT REVIEW REPORT HUNTSVILLE HOSPITAL 101 SIVLEY ROAD HUNTSVILLE, AL 35801 Patient -- A e: 55 Sex: -- Report Name: Emergency Room TRX Iv Fluids and/or Medications Continued on Admission: Restraints continued on admission: (+)Not Applicable, Intake Output (See Table) (ALTERED MENTAL STATUS) EMERGENCY DEPARTMENT History not limited Transferred from: Not transferred HPI: History obtained from patient and Nurses Notes. Patient presents with a chief complaint of 2hrs prior to arrival, while sitting, a sudden and constant onset of neuro WAS SITTING AND DEVELOPED diaphoresis, generalized weakness nausea calls emswas sitting watching tc, no new priro feels dizzi all the time has a very flat affect and seems to ve in a depressed state Last Known Well Verified few hours earlier Other (--)recent exposure to contagious illness, (-)headache, (+)nausea, (-)vomiting, movement, (~)head injury, (-)fall, (-)trauma, (-)disoriented, (--)confused, (-)agitated, (-)difficulty concentrating, (--)difficulty thinking, (--)decreased responsiveness, (-)unresponsive, (+)difficulty standing, (+)difficulty walking, ingestion, (-)drug ingestion, (-)overdose, (?)overmedicated. Glucose check: not applicable to patient are continues in ED and are mild in intensity. Baseline status: alert and oriented, and walks without assistance. worsened by nothing. improved by nothing. Pt has had multiple similar episodes over past years, with frequency of occurring occasionally. Patient was recently treated/seen by Physician type in. (+)recent hospital admission. recent adm neuro and cards eval neg and left heart cath small PFO, PREHOSPITAL CARE: See Nursing Notes. ROS: (-)visual changes, (-)dizziness, (+)unsteady gait, (-)diffiCUltY 8Wa110Wifl9, (-)sore throat, (-)cough, (--)chest pain, (-)palpitations, (-)abdominal pain, (--)diarrhea, (--)bloody stools, (-)dysuria, (--)fever, rash, (--)joint pain, (-)exposure to tick/insect bite, (+)anxiety, (-)depression, (+)all other systems negative. other pertinent addressed in HPI. LMP: LNMP: RESULT REVIEW REPORT HUNTSVILLE HOSPITAL 101 SIVLEY ROAD HUNTSVILLE, AL 35801 Patient>> -- Report Name: Emergency Room PMH List (See PMH Table) anxiety, cva frontal lobe, pfo, hyperlipidemia PSH List (See PSH Table) FH: SOCIAL: (--)tobacco, (--)a1cohol, (-)dru9S VITALS: Note Reviewed. (-)Febrile. (-)Hypotensive, (+)Hypertensive PHYSICAL EXAM: Physical Exam not limited GENERAL APPEARANCE: well nourished, acting strangely, cooperative, no acute distress MENTAL STATUS: speech slow, oriented 3, flat affect, responds slowl NEURO: ?+)hypotonia, cranial nerves 2 - 12 intact, (+)motor intact, (+)sensory intact. HEAD: (-)swe1ling, (-)tenderness EYES: conjunctiva clear. NOSE: no nasal discharge. MOUTH: (--)decreased moisture, no lacerations inside mouth. THROAT: no airway obstruction. NECK: (--)nuchal rigidity, no neck tenderness, (--)thyromegaly. BACK: no back tenderness. LUNGS: (+)lungs clear, no wheezing, no rales, no rhonchi, (-)accessory muscle use HEART: normal rate, normal ABDOMEN: normal BS, soft, no abd tenderness, (-)guarding, (-)rebound, no organomegaly, no abd masses. RECTAL: EXTREMITIES: good pulses in all extremities, (-)swelling, (-)tenderness SKIN: (-)ulcers, (-)decubiti, warm, dry, good color, no rash. DIFFERENTIAL Dx: During the assessment and evaluation, the following were considered. NEURO Dx: volume depletion, hyponatremia, hypernatremia, hypoglycemia, chronic dementia, stupor. issues RESULTS REVIEWED: Laboratory: TROPONIN: unremarkable. CK-MB: unremarkable. CPK: unremarkable. BMP: unremarkable. CBC: normal. Radiology: CHEST Study was radiologist reading and the Radiologist interpretation was reviewed, and the following was noted:, negative. RESULT REVIEW REPORT HUNTSVILLE HOSPITAL 101 SIVLEY ROAD HUNTSVILLE, AL 35801 Patient= -- A e: 56 Report Name: Emergency Room Type: TRX #1 reading): NSR, normal QRS, normal ST, normal T, unremarkable EKG. Strip: Other; Pulse Ox: 99% RA, interpretation: normal saturation. (+)Nursing Notes Reviewed Old Records Reviewed. Changes noted from previous records.. very complete w/u in past which has been neg recent neg brain mri scan ED COURSE: will not stand MEDICATIONS FLUID RESUSCITATION: Patient received IV NS bolus. Patient with improvement of condition. PAIN MANAGEMENT: RESPIRATORY CARE: PROCEDURE: DISPOSITION: Uab School Of Medicine - Int. Med. consulted who will come see pt. CRITICAL CARE TIME: not requested -- Created: 10/15/2012 3:53am Last Entry: Physician Note: MUSCULOSKELETAL: Pulses present on all extremities, no swel1ing\tenderness on the extremities no edema Created: 10/15/2012 6:19am Last Entry: 6:20am Physician Note: i suspect are anxiety hypervent repeat brain MRI will ask uab to readmit Order Sched In Prog Comp MD mucosa, 5; 3:39am 3:39am Ou CBC WITH DIFF 10/15/2012 10/15/2012 Fi 3:51am 4:09am Wi Orders (MDM) (continued) RESULT REVIEW REPORT HUNTSVILLE HOSPITAL 101 SIVLEY ROAD HUNTSVILLE, AL 35801 Patient -- Report Name: BASIC METABOLIC PANEL Type: LAB BASIC METABOLIC PANEL - STATUS: Final ordered By: -- Perform Date: 150ctl2 03:30 Ordered Date: l50ctl2 03:51 Additional Providers Additional Information HL7 RESULT STATUS External IF Update Timestamp Last Updated Date; 15OCtl2 04:25 Facilit HHM Department: CHEM -- Findings Result Name Result Abnl Normal Range Un SODIUM 139 (133-145) ME POTASSIUM 3.9 (3.5-5.0) ME CHLORIDE 103 (96-108) ME CO2 24 (22-29) ME BUN 9 (6-20) MG CREATININE 0.9 MG GLUCOSE 126 (70-100) MG CALCIUM 10.1 MG ANION GAP 12 (7--17) CALC OSMOLALITY 278 MO 10 (10-20) GFR AFRICAN AMERICAN >50 GP GFR NON-AFRICAN AMERICAN >60 GF CHEM COMMENT NONE RESULT REVIEW REPORT HUNTSVILLE HOSPITAL 101 SIVLEY ROAD HUNTSVILLE, AL 35801 Patient: -- A e: 56 Report Name: CBC WITH DIFF Type: LAB CBC WITH DIFF - STATUS: Final Perform Date: l50ctl2 03:30 Ordered Date: l5OCtl2 03:51 Last Updated Date: 150ct12 04:10 Facilitiz HHM Deiartment: HEMA Findings Result Name Result Abnl Normal Range Un WBC COUNT 7.13 (4.8-10.8) x1 REC COUNT 5.17 (4.7-6.1) MI HEMOGLOBIN 16.4 (14.0--1e.0) HEMATOCRIT 47.5 (42.0-52.0) MCV 91.9 (80-98) FL MCH 31.7 (27-34) PG MCHC 34.5 (32--36) RDW 12.6 (11-14) PLATELET COUNT 270 (130-400} X1 MPV 11.4 (9.4--12.4) UN NEUTROPHIL 73.9 (43-75) 17.3 (15-43) MONOCYTE 7.4 (5-15) EOSINOPHIL 0.7 (0-5) BASOPHIL 0.7 (0-1.5) ABSOLUTE NEUTROPHIL COUNT 5.27 (2 09~5.07) x1 ABSOLUTE COUNT 1.23 (1 20-3.40) x1 ABSOLUTE MONOCYTE COUNT 0.53 (0 11--o.s0) x1 ABSOLUTE EOSINOPHIL COUNT 0.05 (0 00-0 70) X1 ABSOLUTE BASOPHIL COUNT 0.05 (0 00-0 20) 1 DIFF TYPE AUTOMATED Additional Providers Additional Information HL7 RESULT STATUS External IF Update Timestamp PROGNO The following Ancllory documumatiun is in and on the MD Patient Profle . - speech notes related to Swalmng Swdies and Spealthg vdve Evaluations - Dietitian notes from provkbr gunemed orders Pruv1dcr3 c'1c|1 on lcam 'And! 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Primary care physician is Neurologist ls-- Cardolcgist i Emergency room physician was- Cl IIEF Shortness of breath with numbness. HISTORY OF PRESENT 55-year-old white male with past med'cal history of CVA in 2011. tinnitus. anxiety disorder. discharged from UAB internal medicine service approximately a week and a half ago. presents again with of shortness of breath with numbress all over his body. Patient states he was sitting in his chair watching TV at one o'clock this morning when he felt "hot." became dizzy. became short of breath, and developed "shaking" that was not witnessed by his wife, and then had numbness beginning in his chest and spreading all over his body including upper extremities. neck and hip. He states he was unable to stop the shaking and was concerned about his breathing and he asked his wife to call HEMSI 'or evaluation. VVl'e states he was siurring his speech. could not walk well. However, he has had balance issues/dizziress since the CVA in 2011. In the emergency room. he was unable to obtain orthostatic blood pressures due to inability to stand due to balance. He was given Zofran and IV normal sa'ine bolus. At the prior admission. he was evaluated with CT and MRI of the head and ecnocardlogram, and diagnosed with panic/anxiety disorder. dizziness secondary to vasovagal PAST MEDYCAL HISTORY: Nephroflthiasis with Iithotripsy, BPH, tinnitus, CVA in 2011. hyperlipidemia. patent foramen ovale. left hip replacement 2 In 2011. SOCIAL HISTORY: He is a heavy machine operator. However. he has not worked since 10/12/2012 He -3 married. He lives at home with his supportive wife. He is a social drinker, on rare occasions he states. no more than a six-pack of beer in a six month period. No tobacco and no illicit drug use. ALLERGIES: No known drug allergies. MEDICATIONSI Meclizine 25 t.i 2. Pravastatin 40 every day. 3. Midodrlne 5 mg t.i.d. 4. Aspirin 81 p.o. every day. 5. Prozac 20 mg every day. 6. Nexium 40 mg every day. 7. Unknown anxiety medicine b.l.d. FAMILY HISTORY: Positive for coronary artery disease in dad who deceased at 80 years of age. Mom; Hypertension, diabetes mellitus REVIEW OF SYSTEMS: Positive for dizziness, tinnitus. shortness of breath. urinary hesitancy. tingling, weakness with difficulty walking and standing secondary to balance. 14-point review of systems is obtained and all other systems reviewed and negative. PHYSICAL EXAMINATION: Temperature is 97.7. heart rate 90, respirations 20, blood pressure while lying 142/98. sitting 132/104, 02 saturation 98% on room air, weight 102 kilograms. GENERAL: No apparent distress. He is awake. alert, and oriented 3 with a flat affect with wife at bedside. HEENT: Normocephalic and atraumatlc. Pupils are equal. round, reactive to light. Extraocular movements are intact. Mucous membranes are moist. No oropharyngeal erythema or edema. NECK: Supple. No Trachea is midline. CARDIOVASCULAR: Regular rate and S1 and No murmurs. gallops or rubs. RESPIRATIONS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi and no retractions and no accessory muscle use. Gl: Soft. nontender and not distended. Positive bowel sounds. No hepetosplenomegaly. MUSCULOSKELETAL: No fasciculatlons. no atrophy. Normal tone. SKIN: Warm, dry and Intact. No rashes. Capillary refill is loss than 2 seconds. EXTREMITIES: No clubbing cyanosis. or edema. 2+ pedal pulses. NEURO: Cranial nerves ll-xii are intact. Motor function bilateral upper and lower extremities is 5/5. Sensory bilateral upper and lower extremities is intact. Reflexes: Peteila brachioradialls Proprlooeption is intact. Cerebellar: Intact finger to nose and rapid alternating hand movements. LABORATORY DATA: WBCs are 7.1. 16.4 and 47.5, and platelets are 270. Sodium is 139, potassium 3.9. chloride 103. bicarbonate 24. BUN 9, creatlnine 0.9. glucose 126 and calcium is 10.1 Troponln--T is 0.011.7 EKG: Normal sinus Portable chest x-ray: No acute findings or cardiopulmonary disease. ASSESSMENT: 55-year-old white male with anxiety disorder. hyperlipldemla. BPH with recent discharge for dizziness secondary to vasovagal 1. Shortness of breath with associated ataxia and paresthesias, lkely underlying anxiety disorder with acute trigger overnight causing hyperventilation given the description. EKG is normal with normal cardiac enzymes. 02 saturation is normal excluding cardiopulmonary etiologies. Shortness of breath had improved by the time of my exam. He was not on oxygen Neuro exam was grossly abnormal. Unable to assess gait, however. He was recently started on SSRI for anxiety He has upcoming hip surgery, which is a possible source for anxiety. and we will consider a evaluation as part of treatment. Previous CT and MRI only showed nonspecific white matter hypersensitive changes. I highly doubt organic etiology for shortness of breath. 2. History of cerebrovascuiar accident. He appears at baseline with his dizziness and balance/ataxia as were persistent prior to arrival. He was evaluated by neurology with carotid Doppler study, orthostatics, and echocardiogram. He has had no new changes and no new changes to medications. We will continue his home vertigo medicines. Midodrlne and Meciizine. 3. Benign prostatic hypertrophy. Continue home made. 4.. Deep vein thrombosis prophylaxis. TEDS and SCDs, Lovenox 40 mg. 5. History of anxiety disorder We will continue SSRI and consider possible evaluation. Robert Centor. M.D. D: 10/15/2012 05:25 A T: 10/15/2012 03:59 cc: Robert Centor, M.D.