- Messages
- 7
- Best answers
- 0
HPI comp
PFSH Comp
ROS Comp
Exam
GA no acute distress
HEENT mucus membranes moist, no conjunctival injection
Fundoscopic exam-optic disc sharp on L, unable to see R
CARDIO
carotids-no bruit
Heart-regular rate and rhythm+cardiac friction rub, no murmurs or gallops
Pulses-palable dorsalis pedis pulses bilaterally
MOTOR
APPEARANCE: ANORMAL BULK, +R>L postural re-emegent tremor, no fasciculations
TONE increased tone in bilateral UE with cogwheeling, bilateral LE rigid
No pronator dift, no obiting, finger taps rapid with decrement bilateraly
Strength ia all extremities
Cranial Nerves: 2
3, 4, 6
5
7
8
9, 10
11, 12 (all tested)
MS:
Orientation
Attention
Memory
Language
Fund of knowledge
(all tested)
sensory, coordination, reflexes, gait (all tested)
assessment
HX of CAD, ischemic cardiomyopathy, HTN, HLD and Parkinson's disease , s/p CABG
presenting with ptosis, found to have L upper lid pstosis, hoarse voice and L miosis on exam consistent
with Horner's syndrome. Suspect ischemic stoke occuring in morning (day before) involving L vertebral artery
(wallenberg syndrome - cardioembolic vs dissection vs. small vessel) or less likely L carotid dissection
Plan
VTE Prophyaxis: yes heparin
Dysphagia Screening was dione before any oral intake. Patient passed Dysphagia Screen
Please obtain CT head and CTA head/neck to evaluate for dissection (patient cannot get MRI)
Con't DAPT
Con't high dose statin
repeat formal swallow evaluation
neuro will cont to follow
Attending Addendum
I preformed a hx and PE of the patient, reviewed diagnostiv tests including electrolytes, renal function, glucose, calcium, complete blood count, hepatic function
coagulation studies and discussed the management with the resident. I reviewed the resident note and agree with the documented findings and plan of care.
PFSH Comp
ROS Comp
Exam
GA no acute distress
HEENT mucus membranes moist, no conjunctival injection
Fundoscopic exam-optic disc sharp on L, unable to see R
CARDIO
carotids-no bruit
Heart-regular rate and rhythm+cardiac friction rub, no murmurs or gallops
Pulses-palable dorsalis pedis pulses bilaterally
MOTOR
APPEARANCE: ANORMAL BULK, +R>L postural re-emegent tremor, no fasciculations
TONE increased tone in bilateral UE with cogwheeling, bilateral LE rigid
No pronator dift, no obiting, finger taps rapid with decrement bilateraly
Strength ia all extremities
Cranial Nerves: 2
3, 4, 6
5
7
8
9, 10
11, 12 (all tested)
MS:
Orientation
Attention
Memory
Language
Fund of knowledge
(all tested)
sensory, coordination, reflexes, gait (all tested)
assessment
HX of CAD, ischemic cardiomyopathy, HTN, HLD and Parkinson's disease , s/p CABG
presenting with ptosis, found to have L upper lid pstosis, hoarse voice and L miosis on exam consistent
with Horner's syndrome. Suspect ischemic stoke occuring in morning (day before) involving L vertebral artery
(wallenberg syndrome - cardioembolic vs dissection vs. small vessel) or less likely L carotid dissection
Plan
VTE Prophyaxis: yes heparin
Dysphagia Screening was dione before any oral intake. Patient passed Dysphagia Screen
Please obtain CT head and CTA head/neck to evaluate for dissection (patient cannot get MRI)
Con't DAPT
Con't high dose statin
repeat formal swallow evaluation
neuro will cont to follow
Attending Addendum
I preformed a hx and PE of the patient, reviewed diagnostiv tests including electrolytes, renal function, glucose, calcium, complete blood count, hepatic function
coagulation studies and discussed the management with the resident. I reviewed the resident note and agree with the documented findings and plan of care.