Identifying Information:
Last Name: Doe
First Name: John
DOB: 7/10/1959
Sex: male Address: Queens, NY
Date: 9/24/19
Time: 10:30 AM
Location: New York Presbyterian Queens
Religion: Unknown
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief Complaint:
“My hand is numb” x 3 hours
History of Present Illness:
Mr. Doe is a reliable 60 y/o Pakistani male with a past medical history of hypercholesterolemia and hypertension. He presented to the Emergency Department 5 days ago with a complaint of complete numbness to his right upper extremity and right side of face. He first noticed the numbness when he was eating his lunch, and he developed weakness in his right upper extremity, at which point he couldn’t pick up his food. The numbness was non-radiating. He states the numbness started at 2:30 PM and resolved that evening. He states during the time his hearing was impaired, he felt heart palpitations, minor slurred speech and subjective high blood pressure. His symptoms were not relieved or exacerbated by anything. He states his father had a stroke. He had no vomiting, headaches, paresthesia, hyperesthesias and there was no visual involvement/impairment. He never smoked.
Past Medical History:
Hypertension for 10 years
Hypercholesterolemia for 4 years No known childhood illnesses
Past Surgical History:
Angioplasty with stent placement 2017. Patient states there were no complications.
Medications:
Amlodipine 10 mg QD by mouth
Aspirin 81 mg QD by mouth
Atorvastatin 40 mg QD by mouth
Metoprolol Tartrate 50 mg QD by mouth
Clopidogrel 75 mg QD by mouth
Tamsulosin 0.4 mg QD by mouth
Allergies:
Penicillin reaction rashes and swelling
Family History:
Mother Hypercholesteolemia alive and well
Father: Hypertension, Stroke deceased unknown cause, unknown age Paternal and maternal grandparents: unknown
Sister: Breast Cancer remission x 3 years. Alive and well
Brother: Alive and well
Daughter: Alive and well
Son: Alive and well
Social History:
Alcohol Use: none
Smoking: never smoked
Illicit Drug Use: none
Travel: no recent travel
Marital Status: married
Sexual Activity: Sexually active with one partner, female partner.
Occupation: Cab driver
Diet: Eats whole grains, organic fruits and vegetables, chicken and fish
Exercise: Walks 20 minutes 6 days a week Sleep: 6-8 hours of sleep per a night
Caffeine: Tea twice a day
Home situation: lives at home with wife and children Safety: uses a seat belt
Review of Systems:
General: no recent changes in weight, no generalized anxiety, fever, chills, night sweats. Recent right upper extremity weakness. Skin, hair and nails: no excessive dryness, seating, discoloration, pigmentation, moles, rashes, pruritus. Normal hair and skin texture.
Head: No headaches, vertigo, head trauma.
Eyes: No blurry vision, diplopia, eye fatigue, scotoma, halos, lacrimation, photophobia, pruritus, glasses. Last eye exam 1 year ago.
Ears: No deafness, pain, discharge, tinnitus, hearing aids. Recent impaired hearing in right ear. Nose/sinuses: No discharge, epistaxis, obstruction. Mouth and throat: No gum bleeding, sore tongue, sore throat, voice changes, dentures. Brushes and flosses daily.
Cardiovascular system: No chest pain, edema of ankles, feet, syncope. He states he has hypertension, heart palpitations, irregular heartbeat, known heart murmur. Neck: No swelling/lumps, stiffness
Musculoskeletal: No muscle/joint pain, deformity, swelling, redness. No arthritis. Nervous system: No seizures, headaches, loss of consciousness, paresthesia, dysesthesias, hyeresthesias, change in cognition. Patient has numbness, ataxia minor slurred speech, loss of strength right upper extremity.
Pulmonary system: No dyspnea, coughing, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea.
Genitourinary system: No frequency, urgency of urination. No oliguria, polyuria, dysuria. No abnormal urine color, no incontinence. No sexually transmitted diseases. Patient has nocturia. Sexually active with one female partner. Patient has imotence/anorgasmia sometimes. Hematologic system: No anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of deep vein thrombosis, history of pulmonary embolism.
Endocrine system: No polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.
Gastrointestinal system: No food intolerance, nausea, vomiting, dysphagia, flatulence, eructations, abdominal pain, diarrhea, jaundice, changes in bowel habits, hemorrhoids, constipation, rectal bleeding, stool guaiac. Recent loss of appetite.
Psychiatric: Patient denies depression, lack of energy, memory, changes in appetite, changes in sleep, hopelessness, hallucinations, increased energy, anxiety.
Exam:
General: Patient appears well groomed, alert and oriented x 3, no apparent distress, well developed.
Vitals:
Blood Pressure:
Right arm seated: 140/80
Right arm supine: 140/80
Left arm seated: 140/80
Left arm supine: 140/80
Respiration: 18 breaths per minute not labored
Pulse: 60, regular
Weight: 180 lbs
Height: 167.64 cm
BMI: 29.1
O2 saturation: 98% in room air
Temperature: 36.8 C orally
Skin: Warm and moist, good turgor, no tattoos, no scars, no face head lesions. No lesions on the rest of the body. No recent skin changes.
Hair: Frontal baldness consistent with male pattern hair loss. No pediculosis capitis, nits, seborrhea.
Head: No deformaties, non-tender to palpation, atromatic, normocephalic.
