Sandbox:ssw 2

Revision as of 16:44, 18 June 2018 by Sargun Walia (talk | contribs) (→‎Event(s))
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Demographic / Medical history

  • Demographic: 77, M
  • Past Medical History: HTN, BPH, CAD w CABG, MI, AVR
  • Past Surgical History:
    • AVR (#25 magna ease valve) on 12/14/17
    • Stent on 10/10/2017
    • CABG in 2007
    • Appendectomy in 1957
  • Medications:
    • Metoprolol
    • DAPT
    • Tamsulosin

Procedure

  • Index Procedure Date/Time:
    • mm/dd/YYYY at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Access site details
    • The site reported that there were/were not procedural complication(s).

Event(s)

Event (1):

  • Site Reported Event Onset Date: 12/26/2017
  • Event summary:
    • Symptoms and sign: Subject presented with
      • Right leg collapse,
      • Right arm and right leg weakness
    • Episodes lasted approximately 2 -10 minutes and ranged from 1-4/day
    • No visual or speech difficulties, no headache or neck pain
    • No history of vertigo, syncope, loss of consciousness or seizures
    • Other important symptoms related to the chief complaint.
    • Physical assessment:
      • Normal neurological exam
      • BP: 124/66
      • HR: 96

Laboratory data

  • Lab studies list: (Date/ name/ value)
    • 01/04/2018 / HDLC / 31
    • 01/03/2018 / INR / 1.2

Diagnostic tests

  • 01/03/2018 TTE
    • Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
    • Moderate left atrial enlargement
    • Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
  • 01/03/2018 MR Brain
    • NO evidence of vascular occlusion
    • No evidence of restricted diffusion to suggest infarction
  • 01/03/2018 MRA H/N
    • Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
  • 01/03/2018 Carotid US(Preliminary)
    • Right: 1-49% stenosis of right internal carotid
    • Left: 1-49% stenosis of left internal carotid
    • Bilateral vrtebral arteries patent with antegrade flow
  • 01/03/2018 EEG
    • Normal awake EEG
    • No epilitiform discharges, focal changes or other abnormalities

Consults

  • Neurology consult : 01/03/2018
  • Recommendations:
    • CBC,CMP
    • Admission to neurology service
    • MRI brain with or without contrast
    • MRA of the extracranial and intracranial circulation
    • Carotid duplex US
    • EEG
  • Date and time of consult
  • Suggested treatments:
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release
  • Out come - Discharged home