Name: Mrs. K

Sex: Female

Address: India

Date of Birth: 1/1/1953, 68 years old

Date & Time: 5/10/21, 9:00 AM

Location: Northshore University Hospital, Manhasset, NY

Religion: Hindi

Marital Status: Married

Race: Indian 

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Ambulance

Chief Complaint: “Loss of Consciousness” 

History of Present Illness

Mrs. K is a 68 year old married Indian speaking female w/ pmhx of DM2, HLD not on meds anymore, Obesity s/p sleeve gastrectomy, HTN, Neuropathy that began prior to her sleeve gastrectomy though has worsened in recent year, hx toe amputation, who presented to NSUH ED on 5/9/21 with episode of loss of consciousness associated with some convulsions. Patient does not recall episode herself and has some mild memory difficulties in recent years (though is at baseline usually sharp per family) so additional information obtained from patient’s son by phone. Patient had been with her husband sitting down cutting some food in preparation for dinner when she suddenly reported not feeling right and feeling as if her vision was darkening. In addition she reported to her husband that she felt very lightheaded. Patient’s husband helped her to bed to see if she would feel better. Patient was not responsive at the time of her son’s arrival about 5 minutes later and he and her husband could not arouse the patient for a few minutes. Patient’s son reports that she seemed to have bilateral arm and leg convulsions though it seemed to be more obvious on the R side, states this has never happened before. When she was aroused, patient initially felt some weakness for a few minutes, but then felt fine. Patient reports pains throughout her entire body chronically for the past 5 years, which comes and goes, with no particular aggravating and alleviating factors, as well as RLE pain at this time which she reports is her neuropathy pain. She rated the pain as a 7/10. She denied current weakness, chest pain, SOB, headache, or dizziness.

When examined on 5/10/21, patient is A/O x3, sitting up in bed eating breakfast, in no apparent distress. She explains that she is feeling good but reports body aches throughout her body, rating it currently as a 5/10, and numbness and tingling in bilateral fingers and toes. Denies weakness, dizziness, headache, SOB. 

Past Medical History:

Present medical illnesses – HLD; Type 2 Diabetes Mellitus; Hypertension; Neuropathy; Obesity

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

Laparoscopic sleeve gastrectomy- 2 years ago, in India

Left Big Toe amputation- 5 years ago, in India

Medications

Home Medication:

1. Janumet 50 mg-1000 mg oral tablet: 1 tab(s) orally 2 times a day, for DM
2. telmisartan-hydrochlorothiazide 40mg-12.5mg oral tablet: 1 tab(s) orally once a day, for HTN
3. gabapentin 100 mg oral tablet: 200 milligram(s) orally 3 times a day, for neuropathic pain

Hospital Medication:

1. Dextrose 5% – solution, 1000 mL infuse at 100 mL/Hr, for DM
2. Insulin lispro (admelog) corrective regimen sliding scale, for DM
3. Acetaminophen tablet (tylenol), 650 mg, oral, every 6 hours, PRN for mild pain
4. Gabapentin (neurontin), 200 milligram(s), oral, every 8 hours, for neuropathic pain
5. Losartan (cozaar) – 50 milligram(s), oral, daily, for htn
6. Thiamine (vitamin B1) – 100 milligram(s), oral, daily
7. Atorvastatin (lipitor)- 40 milligram(s), oral at bedtime, for HLD

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – 91, Alive and Well

Father – Deceased, natural causes

Son- 45, Alive and Well

Son- 41- Alive and Well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mrs. C is a married female, originally from India but residing together with her husband by her son’s house in NY for the past 15 months. She is a retired teacher.

Habits – Patient drinks two cups of tea a day, one in the morning and one at night. Denies drinking alcohol, smoking, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to generally sleeping well, for about 8 hours every night.

Exercise – states she walks around the house with her walker for about 5 minutes following each meal

Diet- patient maintains a balanced, low fat diet including fruits, vegetables, and meat.

Sexual History: Monogamous, has single male partner. Currently sexually active. Admits to using contraception. Denies history of sexually transmitted infections.

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Denies use of glasses, contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. 

Ears –Denies tinnitus, ear pain, hearing loss, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. Last dental exam in February- normal. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Denies dyspnea, dyspnea on exertion, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Admits to hypertension. Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system – Deniesurinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Admits to general body aches and pains throughout bilateral upper and lower extremities. Denies arthritis, deformity or swelling, or redness.

Nervous System– Admits to loss of consciousness. Denies h/o seizures, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Denies depression, anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 41 year old female, alert and oriented to person, place and time. Patient is obese and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 120/62, supine                       

R: 18 breaths/min unlabored     

P:77 beats/min, regular       

T: 97.9 (oral)                      

O2 Sat: 96% on Room air

Height: 63 inches                 Weight: 220 pounds             BMI: 39.0- severely obese

Skin- Warm and dry, smooth, poor turgor, nonicteric, with fistula on left arm for dialysis placement. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence of strabismus, exophthalmos or ptosis.Sclera white conjunctiva and cornea clear.  Visual fields full OU. Visual Acuity 20/20 OD, 20/20 OS, 20/20 OU, PERRL, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact upon whisper test.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. 

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips -Moist; no cyanosis or lesions

Mucosa -Pink, No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. 

Teeth -all teeth intact, good dentition, no cavities noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue –Pink; moist, well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   

Thyroid- Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds. 

Abdomen-Abdomen slightly distended and symmetric with some striae, scar from surgery, no pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment in his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Cranial Nerve Exam – 

CNII-visual fields full by confrontation, red reflex present

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities. Symmetric muscle bulk, no atrophy, no tics, tremors or fasciculation. Strength 5/5 throughout. Romberg negative, no pronator drift noted.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout arms and legs, except bilateral ankles and feet- feels numb. Feels tingling on bilateral fingers and toes, as well as on knee. Tender to palpation of bilateral legs from knees down.  Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes-2+ throughout.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Labs:

Serum Pro-Brian Natriuretic Peptide: 177 [0-300 pg/mL]

Chemistries

Sodium 144 [135-145 mmol/L]

Potassium 5 [3.5-5.3 mmol/L]

Chloride 105 [96-108 mmol/L]

Carbon dioxide 23 [22-31 mmol/L]

Anion gap 17 [5-17 mmol/L]

BUN 24 [7-23 mg/dL]

Creatinine 1.11 [0.5-1.3 mg/dL]

Calcium, total serum 9.7 [8.4-10.5 mg/dL]

eGFR 51 [>60 mL/min/1.73M2]

Troponin T 20 [0-51 ng/L]

Hematology

WBC count 8 [3.80-10.50 K/uL]

RBC count 4.19 [308-5.20 M/uL]

Hemoglobin 10.1 [11.5-15.5 g/dL]

Hematocrit 33.7 [34.5-45%]

Mean cell volume 80.4 [80-100 fl]

Mean cell hemoglobin 28 [27-34 pg]

Mean cell hemoglobin conc 33 [32-36 gm/dL]

Red cell distribution width 14.4 [10.3-14.5%]

Platelet count – 288 [150-400 K/uL]

Cholesterol- 244 [<=199]

Triglycerides- 412 [<=149]

HDL Cholesterol- 43 low [>=51]

non-HDL Cholesterol- 201 [<129]

A1C with estimated average glucose 8.0 [4-5.6%]

POCT Blood Glucose: 275 [70-99 mg/dL]

Hepatitis C Interpretation: Nonreactive

Covid antibody: Positive 

Imaging:

CXR:Low lung volumes with grossly clear lungs. There is no pneumothorax or large pleural effusion. Heart size cannot be accurately assessed in this projection.

No acute osseous abnormality

HEAD CT: No acute intracranial hemorrhage.

CT PERFUSION: Asymmetric patchy region of prolonged Tmax in the region of the right frontal lobe which may be artifactual or represent oligemia.

If symptoms persist consider follow up head CT or MRI, MRA  if no contraindication.

CTA Circle of Willis:  Patent intracranial circulation without flow limiting stenosis. 

CTA NECK: Patent, no hemodynamically significant stenosis 

Assessment

68yo F w/pmhx of DM2, HLD not on meds anymore, Obesity s/p gastric surgery, HTN, neuropathy, hx toe amputation, who now presents with episode of loss of consciousness associated with some convulsions.

Differential Diagnoses:

1. Seizure- appeared to be having convulsions, the feeling of darkness could have been an aura, no history of seizures
2. Stroke- had syncope, and has uncontrolled HLD which is a risk factor for stroke, but did not have continued weakness following episode. Use NIH stroke scale to r/o stroke 
3. Vasovagal Syncope- most common type of syncope, felt lightheaded so it is possible her BP dropped, though no clear precipitating factor
4. Orthostatic Hypotension- Patient suddenly got up and felt lightheaded, has h/o htn on medications, BP is currently running low
5. Hypoglycemia- patient is diabetic, so possible that glucose went really low
6. Heart Arrhythmia- can cause syncope, but never happened before, and no symptoms of chest pain/palpitations/ heart racing
7. Anemia- H/H are slightly low, but not very low and no h/o anemia

Problem List/Plan – 

1. Syncope/ loss of consciousness -LOC seems more likely to be syncope given initial symptoms and largely baseline mental status after regaining consciousness. However, seizure does still remain in differential. Use NIHSS to r/o stroke. Obtain neuro consult/ Check EEG to r/o seizure. Complete cardiac workup, monitor on telemetry, check TTE to r/o cardiac cause. Consider placing patient on holter monitor/ loop recorder. Orthostatic BP’s every 12 hours to r/o orthostatic hypotension.
2. Neuropathic Pain in Legs- PT and OT consult, consider switching gapapentin/ adding another medication for neuropathic pain.
3.  Hyperlipidemia-No longer on simvastatin, lipids are very high. Explain risks associated with HLD, discuss with patient about putting her on different HLD medication
4. Type 2 diabetes mellitus- without long-term current use of insulin. ISS while inpatient. A1C elevated. Current glucose levels very high. Consult endocrinology, consider adding on medication to better control blood glucose
5. Obesity-BMI 35-39.9- Pt with hx of gastric sleeve, has neuropathy, is not on intensive vitamin supplementation. Should have iron studies, folate level, b12 level. May also benefit from thiamine supplementation. May need additional supplementation of these and possibly other micronutrients (i.e. zinc, selenium). Educate patient on healthy eating habits, diet and exercise. 
6. Slightly Low H/H-monitor to make sure doesn’t decrease further, do further testing to determine if this represents anemia
7. Elevated BUN/ Decreased GFR-only slightly elevated/ decreased, can be consistent with normal aging. Monitor to ensure doesn’t worsen, ensure adequate hydration