allergies: no known allergies / adverse drug reactions attending: chief complaint: not speaking, r sided weakness major surgical or invasive procedure: tpa administration tee history of present illness: neurology at bedside for evaluation after code stroke activation within: 1 minutes time (and date) the patient was last known well: 19:45 (24h clock) nih stroke scale score: 23 t-: yes time t-pa was given 21:11 (24h clock) i was present during the ct scanning and reviewed the images instantly within 20 minutes of their completion. hpi: the pt is a 64 y/o rhw with a history of dm, htn presented to the ed after having dinner with her brother then suddenly going mute with a right facial droop. the history was obtained from the brother as the patient could not provide any history. the symptoms came on around 19:45. ems was called. they noted a right hemiplegia. when she came in neuro was made aware before arrival and was there on arrival. she was completely mute at that time. she was able to nod her head to some questions and said no to pain. later on in the day she began to recover some use of her language and did not know why she was in the hospital. her brother said she did have a stroke 20 years ago but he was not aware of what type or the symptoms and as far as he knows had no residual symptoms. past medical history: prior stroke 20 yrs ago htn dm social history: no smoking, etoh, drugs family history: no sz, early strokes physical exam: physical exam on admission: vitals: t: 98 p:80 r: 16 bp:153/80 sao2:100 general: awake nad. heent: nc/at, mmm. neck: supple, no carotid bruits appreciated. pulmonary: lungs cta bilaterally cardiac: rrr, nl. s1s2 abdomen: soft, nt/nd. extremities: no edema or deformities. skin: no rashes or lesions noted. neurologic: nih stroke scale score 1a. level of consciousness: 0 1b. loc question: 2 1c. loc commands: 1 2. best gaze: 2 3. visual fields: 2 4. facial palsy: 3 5a. motor arm, left: 0 5b. motor arm, right: 3 6a. motor leg, left: 0 6b. motor leg, right: 3 7. limb ataxia: 0 8. sensory: 1 9. language: 3 10. dysarthria: 2 11. extinction and neglect: 2 neuro: she was completely mute, was only able to follow some commands like close your eyes, open your eyes, and make a fist but could not show me two fingers, could not stick out her tongue on command. she had a forced left gaze deviation. no blink to threat from the right. her right side was completely plegic including to pain. no grimace to pain on the right. the left side was antigravity at least. toe was up on the right and equivocal on the right. on re-evaluation she was able to speak,. did not know why she was hear, was able to follow commands. had some phonemic paraphasic errors, and only able to name glove, chair, key on the nihss card. she was able to read. there was a right facial droop. eomi were now intact. perrl. there was a subtle ruq quadrantsenopsia. writing was not tested. she had a left pronation drift. ************* physical exam on transfer to floor: significant only for slight r nlf flattening. otherwise speech fluent, naming and repetition intact, answers questions appropriately and follows simple and complex commands. strength is full throughout. ****************** physical exam on discharge: patinet is a+ox3. has slight r nlf flattening. speech is fluent. able to name index finger, knuckle, thumb, button, button hole. motor strength is normal bilaterally in all extremities. sensation is normal. cerebellar function is normal. gait is normal. pertinent results: 08:40pm creat-1.0 08:40pm estgfr-using this 08:38pm urea n-27* 08:38pm glucose-191* na+-143 k+-4.3 cl--102 tco2-24 08:38pm wbc-10.1 rbc-5.72* hgb-12.2 hct-39.8 mcv-70* mch-21.3* mchc-30.6* rdw-15.9* 08:38pm plt count-256 08:38pm pt-10.6 ptt-33.1 inr(pt)-1.0 04:56am blood %hba1c-6.7* eag-146* 04:56am blood triglyc-123 hdl-46 chol/hd-3.6 ldlcalc-95 ct/a/p: plain ct negative for acute process. cta shows occlusion of proximal l mca with large perfusion deficit in l mca territory on ctp. mri brain : impression: 1. two small foci of slow diffusion in the left frontal and parietal regions as described above, likely represent acute infarcts. 2. volume loss with chronic blood products in the left basal ganglia may represent a sequela of prior hemorrhage or infarction. 3. small vessel ischemic disease. 4. few scattered foci of abnormal susceptibility in bilateral cerebral hemispheres may represent microhemorrhages or cavernomas. . tte: the left atrium is normal in size. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is no pericardial effusion. . brief hospital course: is a 64 yo woman with history of dm, htn, and a prior stroke 20 years ago (unclear characterization, no residual symptoms) who presented with acute onset aphasia and r sided weakness, consistent with l mca syndrome. she presented within 1 hour of symptom onset and was given iv tpa within 1.5hrs at 21:11. her symptoms had begun to improve prior to tpa but continued to have some naming difficulties, r sided weakness, and subtle r upper quadrantanopsia. she was admitted to the icu for post-tpa monitoring and remained stable overnight. her neurological symptoms resolved with the exception of slight r nlf flattening. neuro: bp was closely controlled with goal sbp < 180. she was maintained on close neurochecks overnight and remained stable. antiplatelets/anticoagulants and venipunctures were avoided for the first 24 hours post-tpa. by the morning of her exam had markedly improved and she was essentially back to baseline except for mild r nlf flattening. mri showed two small infarcts in the left frontal and parietal lobes. lipid panel was significant for ldl of 95, hba1c was 6.7%. on hd 3, the patient went into atrial fibrillation. she was given 10mg metoprolol iv. 30 minutes later, she went into sr. the decision at this point was made to switch her daily home atenolol dose to metoprolol. furthermore, the patient was started on pradaxa in place of plavix. a tee that was scheduled for that day was cancelled, given the likely source of the stroke had been identified. the remaining home antihypertensives were started as usual. cardiovascular: she was maintained on telemetry monitoring. bp was closely monitored as above. home lisinopril and nicardipine were held, and atenolol was given at half of home dose (50). she was also started on plavix. tte showed no abnormalities. on hd3, the patient went into atrial fibrillation for approximately 30 minutes. she exhibited rvr to 150s. she was given 10mg iv lopressor to help control the rate. given that the likely source of her stroke had been identified, the patient's home atenolol was changed to metoprolol, and she was started on pradaxa. her scheduled tee was cancelled. her simvastatin was changed to atorvastatin given her elevated ldl. this was done after confirming that this would be ok with the pcp. home antihypertensives were restarted on hd 2 (with atenolol being switched to metoprolol on hd 3) pulm: respiratory status was monitored and she remained stable on ra. heme: she had no clinical signs of bleeding post-tpa. hct on had decreased a bit from 39.8 -> 35.2, likely at least partially dilutional. this was repeated and improved without intervention. all antiplatelets and anticoagulants were held for 24 hrs post-tpa. she was started on plavix after this period. on hd 3 after going into afib, the patient was started on pradaxa and plavix was discontinued. id: she remained afebrile with no signs of infection during her icu stay. endo: she was maintained on fingersticks achs and an insulin sliding scale. her home metformin and glipizide were held until discharge. a1c was 6.7%. pending results: none transitional care issues: patient will need to be maintained on pradaxa and get her ptt checked in the future to ensure it is effective. medications on admission: metformin 1g glipizide 5mg atenolol 100 qd nifedipine er 60 qd lisinopril 20 qd discharge medications: 1. atorvastatin 80 mg po daily rx *atorvastatin 80 mg daily disp #*30 tablet refills:*2 2. lisinopril 20 mg po daily 3. nifedipine cr 60 mg po daily 4. metformin xr (glucophage xr) 1000 mg po bid do not crush 5. dabigatran etexilate 150 mg po bid rx *pradaxa 150 mg twice a day disp #*60 tablet refills:*2 6. metoprolol succinate xl 75 mg po daily rx *metoprolol succinate 25 mg daily disp #*90 tablet refills:*2 discharge disposition: home discharge diagnosis: acute ischemic stroke atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. neurologic: no deficits discharge instructions: dear ms. , you were hospitalized due to symptoms of inability to speak and weakness resulting from an acute ischemic stroke, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. the brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. in order to prevent future strokes, we plan to modify those risk factors. we are changing your medications as follows: 1. please take pradaxa twice a day to prevent blood clots 2. please switch atenolol to metoprolol daily 3. please take atorvastatin daily in place of simvastatin please take your other medications as prescribed. please followup with neurology and your primary care physician as listed below. if you experience any of the symptoms below, please seek medical attention. in particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake it was a pleasure providing you with care during this hospitalization. followup instructions: department: neurology when: tuesday at 1:30 pm with: , md, phd building: sc clinical ctr campus: east best parking: garage md, Procedure: Injection or infusion of thrombolytic agent Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Cerebral embolism with cerebral infarction Aphasia Muscle weakness (generalized)