Question

Neurology Consult Note

Admission Date: 9/28/2015 LOS: 0 days
Reason for Consult: stroke activation

Consult type: Opinion with orders

Assessment/Plan

51 year old male with PMH of DM, HTN, HLD, and CVA 3 months ago presents to the ED with sudden onset of left sided weakness. Last known normal was 23:30 and presented to the ED around 01:15am. NIHSS 12 for left sided weakness, sensory changes and extinction and mild dysarthria. Head CT showed right thalamic and corona radiata hemorrhage. Patient is not a tPA candidate due to hemorrhage.

Head CT- right superior thalamic/medial right coronal radiata intraparenchymal hemorrhage with mild right lateral intraventricular extension. No significant hydrocephalus. 3rd ventricle is only minimally effaced. No evidence of herniation. 2 small adjacent foci of low density in the central pons likely from older ischemia.
BP 201/101
Gluc 83

Recommendations:

• neurosurgery consult
• consider admission to NEICU
• goal BP systolic less than 140-
• cardene drip initiated
• defer work up of shoulder pain from fall to ED

History of Present Illness:

is a 51 y.o. male with DM, HTN, HLD, and recent CVA presents to the ED with left sided weakness. He reports that he went to watch TV around 23:30 and around midnight he tried to pick up the remote and wasn't able to pick it up. He fell out of the bed trying to get up. He reports he was having a hard time calling out to his wife. His wife reports that he was last known normal around 23:30.
He reports that he takes aspirin daily but has not been taking his blood pressure medications because he cannot afford them.

Past Medical History

Diagnosis

• Insulin dependent diabetes mellitus
• HTN
• CVA
• Asthma

No past surgical history on file.

History:

Social History:

• Marital Status:    Married
• Spouse Name:N/A
• Number of Children:N/A
• Years of Education:N/A
• Smoking status: Former Smoker – 4 packs/day for 37 years Quit date: 1/1/2006
• Smokeless tobacco:Not on file
• Alcohol Use:0.6 oz/week    1 Can of beer per week
• Drug Use:No
• Sexual Activity:Not on file
• Family History: Not on file

Allergies: Review of patient's allergies indicates no known allergies.

Scheduled Meds:

Continuous Infusions:

• niCARdipine (cardENE) 20 mg/NS 200 mL infusion (std 5 mg/hr (09/28/15 0138) conc)(premade)

PRN and Respiratory Meds: none

Review of Systems:

A comprehensive review of systems was negative except for: Musculoskeletal: positive for shoulder pain
Neurological: positive for speech problems, paresthesia and weakness

BP: 201/101 mmHg (09/28 0135)
Temp: 36.6 °C (97.9 °F) (09/28 0137)
Pulse: 106 (09/28 0137)
Respirations: 17 PER MINUTE (09/28 0137)
SpO2: 99 % (09/28 0137)
O2 Delivery: None (Room Air) (09/28 0137)
SpO2 Pulse: 106 (09/28 0137)

Physical Exam:

• General: awake, alert
• Head/Neck: AT/NC, supple
• ENT: moist mucus membranes
• Respiratory: CTAB, good air movement
• CV: tachycardic, regular rhythm, no murmur appreciated
• Abdomen: soft
• Skin: pink, warm, dry, abrasions on left shoulder

Neuro:

• General: awake, alert, sitting up in bed, speech with mild dysarthria, voice strong
• CNS: left sided facial droop but symmetric smile, EOMI with nystagmus on right gaze, PERRL, visual fields intact, voice strong, uvula midline, facial sensation intact, hearing grossly intact, left side shoulder shrug weak, tongue midline with symmetric horizontal movements,
• Motor: no movement of left arm or leg, 5/5 strength in right arm and leg
• Reflexes: DTR 2+ patellar bilaterally, 0 at ankle, 2+ right bicep and brachioradialis, 3+ left bicep and brachioradialis, toes withdrawal bilaterally
• Sensory: decreased to light touch on left compared to right
• Coordination: finger to nose and heel to shin on right without dysmetria, left not able to be tested due to weakness

Gait: Deferred due to weakness

Extended Neuro Exam

NIH Stroke Scale Item	Scoring Definition	Score
1a. LOC	0=alert and responsive 1=arousable to minor stimulation 2=arousable only to painful stimulation 3=reflex responses or unrousable	0
1b. LOC questions-as patient’s age and month. Must be exact.	0=both correct 1=one correct (or dysarthria, intubated, foreign language) 2=neither correct	0
1c. Commands-open/close eyes, grip and release non-paretic hand (other 1 step commands or mimic OK)	0=both correct (ok if impaired by weakness) 1=one correct 2=neither correct	0
2. Best Gaze-horizontal EOM by voluntary or Doll’s	0=normal 1=partial gaze palsy (abnormal gaze in one or both eyes) 2=forced eye deviation or total paresis which cannot be overcome by Doll’s	0
3. Visual Field-use visual threat if necessary. If monocular, score field of good eye	0=no visual loss 1=partial hemianopia, quadrantanopia, extinction 2=complete hemianopia 3=bilateral hemianopia or blindness	0
4. Facial Palsy-if stuporous, check symmetry of grimace to pain	0=normal 1=minor paralysis, flat NLF, asymm smile 2=partial paralysis (lower face=UMN) 3=complete paralysis (upper and lower face)	1
5. Motor Arm-arms outstretched 90 deg (sitting) or 45 deg (supine) for 10 seconds. Encourage best effort.	0=no drift x 10 seconds 1=drift but doesn’t hit bed 2=some antigravity effort, but can’t sustain 3=no antigravity effort, but even minimal mvt counts 4=no movement at all X=unable to assess due to amputation, fusion, etc	L/R 4/0
6. Motor Leg-raise leg to 30 degrees supine x 5 seconds	0=no drift x 5 seconds 1=drift but doesn’t hit bed 2=some antigravity effort, but can’t sustain 3=no antigravity effort, but even minimal mvt counts 4=no movement at all X=unable to assess due to amputation, fusion, etc	L/R 4/0
7. Limb Ataxia-check finger- nose- finger; heel-shin; and score only if out of proportion to paralysis	0=no ataxia (or aphasic, hemiplegic) 1=ataxia in upper or lower extremity 2=ataxia in upper AND lower extremity X=unable to assess due to amputation, fusion, etc	L/R 0/0
8. Sensory-use safety pin. Check grimace or withdrawal if stuporous. Score only stroke- related losses	0=normal 1=mild-mod unilateral loss but patient aware of touch or aphasic, confused) 2=total loss, pt unaware of touch. Coma, bilateral loss	1
9. Best Language-describe cookie jar picture, name objects, read sentences. May use repeating, writing, stereognosis	0=normal 1=mild-mod aphasia (diff but partly comprehensible) 2=severe aphasia (almost no info exchanged) 3=mute, global aphasia, coma. No 1 step commands	0
10. Dysarthria-read list of words	0=normal 1=mild-mod; slurred but intelligible 2=severe; unintelligible or mute	1
11. Extinction/Neglect- simultaneously touch patient on both hands, show fingers in both visual fields, ask about deficit, left hand	0=normal, none detected. (visual loss alone) 1=neglects or extinguishes to double stimulation in any modality 2=profound neglect in more than one modality	1
Score		12

Lab/Radiology/Other Diagnostic Tests:

Pertinent labs reviewed
Pertinent radiology reviewed.


CT HEAD W/O CONTRAST IMPRESSION:

1.RIGHT SUPERIOR THALAMIC/MEDIAL RIGHT CORONAL RADIATA INTRAPARENCHYMAL HEMORRHAGE WITH MILD RIGHT LATERAL INTRAVENTRICULAR EXTENSION. THERE IS NO SIGNIFICANT HYDROCEPHALUS. THE 3RD VENTRICLE IS ONLY MINIMALLY EFFACED.

2.NO EVIDENCE OF HERNIATION.

3.TWO SMALL ADJACENT FOCI OF LOW DENSITY IN THE CENTRAL PONS, LIKELY FROM OLDER ISCHEMIA.

Condense this report down to just a few (2-4) sentences explaining to your non-medical grandma what all this is saying about grandpa who has been brought into the ER. She doesn't understand what the doctors are telling her, so you need to explain what is in this report in layman terms that she can understand.

Answer 1

Explanation to grandma - Grandpa has left sided weakness due to bleed in the right part of brain due to raised blood pressure because of not taking the blood pressure medications . Otherwise he is OK.