Facial Droop History and Physical Transcription Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left-sided facial droop and slurred speech.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman with a past medical history of hypertension, diabetes mellitus, chronic atrial fibrillation, on Coumadin, and history of stroke and transient ischemic attack in the past who lives at home with her son and is cared for by multiple family members.
Her daughter provides most of the history of present illness. She states that, over the past 1 to 1-1/2 weeks, the patient has had a cough occasionally productive of phlegm. There have been no fevers. The daughter reports chills. There has been no change in shortness of breath.
She was noted by her family to have new slurred speech and left facial droop on the evening of MM/DD, symptoms waxed and waned. Paramedics brought her to the emergency department. She was evaluated by the neurology team, and there was concern for transient ischemic attack. CT scan of the brain was negative for acute stroke. She was also noted to have pneumonia on chest x-ray for which she is being admitted to General Internal Medicine.
Her daughter states that, over the past 1 week, she has had a new cough. She coughs more when she is lying in bed and occasionally coughs during mealtime. In general, she has been weaker over the recent past and has fallen 3 to 4 times in the past 1 week. Her daughter feels this is secondary to leg weakness and possibly clumsiness.
The patient uses a walker with ambulation but usually has someone next to her. There has been no loss of consciousness though she has had mild head trauma to her forehead as well as an abrasion to her right knee. The patient has been noted to be very sleepy during the day and occasionally during meals, though this has been going on for a while.
She has good p.o. intake. She has stable dyspnea on exertion. There has been no new chest pain. She has occasional nausea though no recent vomiting or abdominal pain. Bowel movements have been stable. She has no urinary symptoms and no lower extremity edema. Occasionally, the patient is confused with occasional delusions.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Asthma.
4. Obesity.
5. Chronic renal insufficiency.
6. Venous stasis.
7. Atrial fibrillation, status post cardioversion with recurrence.
8. Stroke complicated by hemorrhage after being started on Coumadin. The patient was continued on Coumadin given her high risk of embolic strokes, which seemed to outweigh her risk of further bleeding.
9. Bilateral total knee replacement.
10. Glaucoma.
11. Partial hysterectomy.
12. Hyperthyroidism with toxic multinodular goiter in the past.
13. Status post cholecystectomy.
14. Appendectomy.
15. History of gastric and duodenal ulcers in the past.
16. Left foot fracture in the past.
17. Left hip degenerative joint disease.
18. Tubular adenoma in the past.
19. Frequent falls.
MEDICATIONS ON ADMISSION: Diovan 160 mg b.i.d., Advair 100/50 one puff twice daily, omeprazole 20 mg b.i.d., metoprolol 100 mg t.i.d., Coumadin 5 mg on Saturday, Sunday, Tuesday, and Thursday; 7.5 mg on Monday, Wednesday, and Friday, oxybutynin ER 10 mg daily, folic acid 1 mg daily, citalopram 20 mg daily.
ALLERGIES: Sulfa, penicillin and Keflex.
SOCIAL HISTORY: The patient lives with her son. Her son is her healthcare proxy. Her children share in her care. She does not smoke or drink. She walks with a walker.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Initially, her blood pressure was 188/98. It has come down to 142/78, pulse 72, respiratory rate 18, oxygen saturation 98% on 2 liters, temperature 98.6. General: The patient is an obese woman in no acute distress. HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Oropharynx: Dry mucous membranes. Cardiac: Regular rate and rhythm. Normal S1, S2. Lungs: Decreased breath sounds at the right base, otherwise clear. Abdomen: Bowel sounds present, soft, nontender, nondistended. Extremities: No cyanosis, clubbing or edema. There is an abrasion on her right knee. Neurologic: The patient’s face is symmetric. There is no evidence of left facial droop. She is answering basic questions, though is hard of hearing which limits her communication.
LABORATORY DATA: First set of cardiac enzymes are negative. BNP 191. Electrolytes notable for glucose of 130. INR 1.5, PTT 36. CBC: White blood cell count 7.62, hematocrit 42.6 and platelets of 242. ESR is 7. Urinalysis: Trace protein. Otherwise normal.
DIAGNOSTIC DATA: Chest x-ray reveals a right pleural effusion and right base atelectasis versus consolidation. EKG: Atrial fibrillation 69 beats per minute, right bundle branch block, old.
ASSESSMENT AND PLAN:
1. Pulmonary. The patient has had symptoms suggestive of pneumonia and chest x-ray suggestive of pneumonia. She will be started on Levaquin. Given her risk of aspiration, swallow evaluation is requested. NPO except for medications for now.
2. Neurologic: The patient has been evaluated by the neurology service. It has been recommended that she be covered with heparin until her INR is therapeutic. Carotid ultrasound in the morning as well as echocardiogram. Neurology service will be following.
3. Hypertension. Continue beta blocker and Diovan.
4. Prophylaxis. Continue PPI and Coumadin.
5. Atrial fibrillation. Continue Coumadin and beta blocker.
6. The patient is DO NOT RESUSCITATE.
