Unusual Symptoms

Doctor's File Notes UCSF ED Visit August 21, 2023

ED Provider Notes

Attestation signed by JSF at 8/24/2023 1:25 AM
08/24/23

ATTESTATION:
My date of service is 8/21/2023. I was present for and performed key portions of the examination of the patient. I am personally involved in the management of the patient. I agree with the findings and care plan as documented by the resident.

EMERGENCY DEPARTMENT PHYSICIAN NOTE
ED Attending(s): JSF 8/21/2023 15:37

Chief Complaint
Patient presents with
*Poor balance
Loss of balance since midnight - noticed when walking to bathroom with associated fall injuring R lower ribs (no trouble breathing, no LOC), No pronator drift, no facial asymmetry. Chronic hand tremors noted. Code stroke called 1522.

HISTORY

Medical History

• Adrenal adenoma: Surveillance
• Allergic state
• Anemia
• Blood transfusion without reported diagnosis
• Cancer (CMS code) Colon
• Chronic fatigue
• Complication of anesthesia
• Depression
• Elevated PSA
• Fibromyalgia
• GERD (gastroesophageal reflux disease)
• Glucose intolerance (impaired glucose tolerance)
• Hip fracture, left (CMS code) 9/2013
• Hypercholesteremia
• Osteopenia
• Other mechanical complication of prosthetic joint implant 02/04/2015
• Peyronie's disease
• Polyp of colon
• Last colonoscopy 2011, due every 2-3 years
• Prostate disorder
• Atypical cells on 3/2013 biopsy repeat due 2/2014
• Pseudoparasitic dysesthesias (CMS code) Water
• Pure hypercholesterolemia
• Renal insufficiency
• Tremor

Physical Exam

• Constitutional:
• General: He is not in acute distress

• HENT:
• Head: Normocephalic and afraumatic.
• Right Ear: External ear normal.
• Left Ear: External ear normal.
• Nose: Nose normal.
•  
• Mouth/Throat:
• Mouth: Mucous membranes are moist.
• Pharynx: Oropharynx is clear.
•  
• Eyes:
• Extraocular Movements: Extraocular movements intact
• Conjunctiva/sclera: Conjunctivae normal.
• Pupils: Pupils are equal, round, and reactive to light.
•  
• Cardiovascular:
• Rate and Rhythm: Normal rate and regular rhythm.
• Pulses: Normal pulses.
• Heart sounds: Normal heart sounds.
•  
• Pulmonary::
• Effort: Pulmonary effort is normal.
• Breath sounds: Normal breath sounds.
•  
• Chest::
• Chest wall: No tenderness.
•  
• Abdominal::
• General: Abdomen is flat. There is no distension.
• Palpations: Abdomen is soft.
• Tenderness: There is no abdominal tenderness.
•  
• Musculoskeletal::
• General: No swelling, tenderness, deformity or signs of injury. Normal range of motion.
• Cervical back: Normal range of motion. No tenderness.
•  
• Skin:
• General: Skin is warm and dry.
• Capillary Refill: Capillary refill takes less than 2 seconds.
• Findings: No erythema or rash.
•  
• Neurological::
• Mental Status: He is alert and oriented to person, place, and time.
• Cranial Nerves: No cranial nerve deficit.
• Sensory: No sensory deficit.
• Motor: No weakness.
• Coordination: Coordination normal.
• Gait:

  Gait abnormal (unsteady gait and balance, Romberg neg)

• Comments: Bilateral hand tremors at baseline.

Medical Decision Making

Ddx includes CVA, TIA, intracranial hemorrhage/mass, seizure (although no abnormal movements seen), hypotension (BP normal since arrival), infectious etiology (although no signs or symptoms), electrolyte/metabolic abnormality. Exam only notable for unsteady gait and balance. No other focal neurological deficits found. On labs, lactate elevated to 5.4 with unclear source since low concern for seizure, no recent decreased PO intake/vomiting, no abdominal or chest pain, no substance use. CXR normal without any focal consolidation or edema.

• Plan
• IVF
• neuro recs
•  
• Amount and/or Complexity of Data Reviewed
• Labs: ordered.
• Radiology: ordered.
• ECG/medicine tests: ordered
•  
• Risk
• Prescription drug management

Consults

Mr. R is a 81 year old man with fibromyalgia, history of MDD, who presented with acute gait difficulty and was activated as Code Stroke. He noted instability when getting up to urinate at night and fell down without head strike. He went back to bed and slept but yesterday morning continued to feel unstable and so came to ED. He had NIHSS 0 and did not receive IV tPA; CT Angiogram, showed no evidence of LVO. Per chart, his medications include: Amitriptyline, NuVigil, Brexpiprazole, Wellbutrin, Gabapentin, Norco as needed, Methylphenidate, Melatonin, and, Ziprasidone. Of note, he recently started tricyclic and decreased Wellbutrin dosing.

• MS awake and alert, sitting up in bed, oriented and fluent speech
• CN slowed saccades and mild restriction of upgaze. face symmetric with smile, no nystagmus noted today
• MOTOR no pronator drift, full strength in arms and legs.
• COORD rigidity right>left arm increases with distraction, mild decrement and clumsiness of RAM right>left hand (mild), and mild tremor with FNF testing but accurate.
• SENS absent vibration in feet, diminished at ankles, intact over knees
• REFLEX 2+ at knees and 2+ at ankles
• GAIT stands up and slightly wide based, tentative, stopped with decreased arm swing and en bloc turning.

• MDM Complexity Data
• Of the results, reviewed the following key test results. Na and urine culture, I reviewed notes outside my specialty: ED, outpatient Urology
• Reviewed and interpreted the following studies: MRI Brain and C-spine showing no acute pathology.
• Spoke with Dr. Gandhi from Emergency Department regarding dispo planning.

• Labs: Na 138 Cr 1.17 WBC 7.1 Hct 37.5 Pits 204
• CT Stroke Protocol: "No acute intracranial hemorrhage, hydrocephalus, or herniation. No large vessel intracranial occlusion or significant arterial narrowing in the head or neck. Multilevel cervical spondylosis, as described, with possibly severe narrowing of the bony spinal canal at C7-T1. The degree of bony canal stenosis is likely not significantly changed since 2015."
• MRI Brain: No acute stroke; small meningioma.
• MRI C-spine: "Mild deformity of the right lateral cord at C5-C6 due to external mass effect. No convincing evidence of any true cord signal abnormality." Multilevel DJD.
• U/A: +nitrite and LE, urine culture:>100K E.coli.

MDM Complexity of Problems
Illness/injury posing threat to life or bodily function: Gait Difficulty and falls.

MDM Complexity Risk
No additional complexity risk

Problem List/Plan
81 year old man with MDD, fibromyalgia, polypharmacy on multiple CNS active medications including stimulants, serotoninergic medications, and neuroleptics (no significant recent changes aside from cross-tapering of Wellbutrin with Amitriptyline) who came to ED with fall last night and gait imbalance.

• 1. Gait Imbalance. I suspect that this is multifactorial; he has Parkinsonism on examination that is most likely drug-induced given chronic neuroleptic exposure; he has sensory loss in his feet which could be due to neuropathy or cervical myelopathy; polypharmacy; and now possible UTI (which could be acute trigger)
• We recommended the following:
• --treatment of UTI with antibiotics
• --formal orthostatics and fluids if needed
• --agree with PT evaluation may need walker short-term
• --minimize/wean polypharmacy of CNS active medications if possible with PCP and outpatient neurology team
• --f/up with Spine Clinic given cervical stenosis, although no cord signal change to ensure no progression over time
• --neuropathy/medical myelopathy work-up including HIV, RPR, HgbA1c, SPEP, and Vitamin B12
•  

Patient has outpatient neurologist and can f/up with them to address above follow-up issues. He should also f/u with PCP. Discussed with ED Dr. G myself.

• NEUROLOGY INITIAL CONSULT NOTE

• Consult requested by attending Dr. JSF, MD of the ED service.
• CC:Code Stroke
•  
• Interpreter Use Documentation
• Preferred language: English
• If non-English, interpreter modality: N/A - patient's preferred language is English
• If interpreter used, document name/Id. If no interpreter used, specify why: N/A - patient's preferred language is English

TJR is a 81 y.o. man with a history of fibromyalgia presenting with acute gait instability. Neurology was consulted for code stroke.

Patient last seen normal 12AM 8/21. Patient was in usual state of health until he got up at night to urinate and noticed he was very unstable. He fell over, no head strike or LOC, then headed to bed again and went to sleep. He woke up today and noticed he was still feeling unstable having trouble turning while walking, and decided to present to the ED as he was not improving.

Patient denies ever having this type of symptom before, denies headaches, vision troubles, dizziness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea.

Patient was followed by neurology in 2022 for post-viral fatigue and myalgias. Patient states he has had bilateral tremors for many years but never saw a doctor for this.

• Initial NIH Stroke Scale
• Level of Consciousness: 0
• LOC Questions: 0
• LOC Commands: 0
• Best Gaze: 0
• Visual: 0
• Facial Palsy: 0
• Motor Arm, Left: 0
• Motor Arm, Right: 0
• Motor Leg, Left: 0
• Motor Leg, Right: 0
• Limb Ataxia: 0
• Sensory: 0
• Best Language: 0
• Dysarthria: 0
• Extinction and Inattention: 0
• TOTAL (NIH Stroke Scale: 0
• (08/21.23 1534: KPI, MD)

CT stroke protocol showed no evidence of intracranial hemorrhage, large territory ischemic infarct, hydrocephalus, herniation, midline shift, mass effect, or large vessel occlusion.

Patient was not a tPA candidate and did not receive IV therapy due to out of window. Given absence of large vessel occlusion patient was not an endovascular thrombectomy candidate.

• *Adrenal adenoma: Surveillance
• *Allergic state
• *Anemia
• *Blood transfusion without reported diagnosis
• *Cancer (CMS code) Colon
• *Chronic fatigue
• *Chronic fatigue syndrome
• *Complication of anesthesia
• *Depression
• *Elevated PSA
• *Fibromyalgia
• *GERD (gastroesophageal reflux disease)
• *Glucose intolerance (impaired glucose tolerance)
• *Hip fracture left (CMS code) 9/2013
• *Hypercholesteremia
• *Osteopenia
• *Other mechanical complication of prosthetic joint implant 02/04/2015
• *Peyronie's disease
• *Polyp of colon. Last colonoscopy 2011, due every 2-3 years
• *Prostate disorder. Atypical cells on 3/2013 biopsy; repeat due 2/2014
• *Pseudoparasitic dysesthesias (CMS code) Water
• *Pure hypercholesterolemia
• *Renal insufficiency
• *Tremor

• Medications:

• HOME MEDICATIONS (per Apex)

• (Not in a hospital admission)
•  

• CURRENT INPATIENT MEDICATIONS

• Scheduled Meds:
• *sodium Chloride 1,000mL Intravenous Once
• bolus
•  
• Continuous Infusions:
• PRN Meds: 0.9% sodium chloride flush

Allergies:

• Family History:
• No family history of neurologic disease

• Physical Examination:
• BP 124/64 (BP Location: Right upper arm, Patient Position: Lying) ❘ Pulse 88 ❘ Temp 36.8 ℃ (98.2℉) (Oral) ❘ Resp 18 ❘ Wt 75.3 kg (166 lb) ❘ SpO2 95% ❘ BMI 23.82 kg/m²
• Constitutional; Appears in no apparent distress.
• EYES: mo scleral icterus, conjunctiva normal
• ENT: Mucus membranes moist
• RESP: Breathing comfortably on room air
• CV: WWP
• GI: Soft, non-tender to palpation
• MSK: No cyanosis or edema of the exztremities, no joint deformities
• SKIN: No vissible skin lesions or rashes

Reflexes: R/L: Bi 3/3, Brachiorad 3/3, Patella 3/3, Ankle jerka 2+/2+
Sensory: Intact to LT throughout. UTA Romberg as he is unable to stand steady with eyes open.
Coordination: Intact FNF, HTS
Gait: Difficult to assess given postural instability. ?wide base gait, holding on to walls while walking, 7 step turns.

LABS:
Recent Labs

No results found for: COCC, COCF, GMAN, T253, P256N, P284. H1377, H2377. T339, VDRL, VZGC. VZMC, CMVMIS, EBVMIS, TOXO, TOGM, HIVAA1, LYMET, HCV, HBABQ, CORM, HBSAG, HTLV12. TREP, QTFN, LEGAU, VCAM, EBNA, CMVQT, T401, T290

No results found for: RF, AP3A, AMYE, TGAB, ATPO, ANA, DSDNA, C3, C4, GAD, GD1A, GD1AM, GQ1B, SSB, RO52, RO60, TRANSGLU, CYCP, IGM, IGG, ESR, CRP, CRYF, CRYGL, HEXA, ACLM, ACLG, B2GPG. B2GPM, ENCES, ENCEC, NMO

Exam concerning for rigitity, bradykinesia, tremor, en block turning concerining with parkinsonism as well as wide base gait, holding on to walls of c/f sensory ataxia. Patient also reported lightheadedness when changing positions c/f orthostasis. Overall, presentation multifactorial. Given acuiy of symptom onset per patient, recommend MRI focused brain and C-spine as he also fell and has hyperreflexia. Given signs of sensory ataxia, though no numbness on exams, recommend neuropathy labs (A1c, SPEP. B12). Finally. as a patient is reprting lighthhededness and has an elevated lactate, recommend orthostatic vitals and fluids as needed.

• Recommendations
• -MRI focused brain and c-spine
• -Labs: A1c, SPEP, B12
• -Orthostatic vitals
•  
• These recommendations were discussed verbally with Dr. G from the ED service. Please page 443-COMA with any questions.
•  
• Signed,
• WG MD
• 8/21/2023
•  
• PP at 8/22/2023 9:30 AM

• Physical Therapy Problem Focused Evaluation Note

•  
• PROBLEM FOCUSED EVALUATION
•  

• Charting Type: Initial Evaluation

• Treatment Number: 1
• Patient's Medical Dioagnosis, Past Medical History, Medications and other PT pertinent information have been reviewed: Yes
• Medical Review Comment: Patient is an 81 year old male with hx of fibromnyalgia and multiple prior cancers (colon/esophageal/prostate) p/w acutely worsened gait sincee 8/21 w/ falling to the L side (no trauma proir to gait difficulties) f/t/h cervical degenerative changes most severe at C5-C6 with central canal narrowing without cord signal change and R>L neuroforaminal stenosis from C2-C6. MRI Brain revealed an incidental 1.0 cm R frontal dural based mass without local mass effect or sulcal effacement concerning for a meningioma.
•  
• Prior Level of Function-information attained from: Chart Patient
• Patient is functioning at or near baseline level of function: Yes

Assessment: Patient is an 81 year old male with hx of fibromyalgia and multiple prior cancers (colon/esophageal/prostate) p/w acutely worsened gait since 8/21 w/ falling to thet L side (no trauna prior to gait difficulties) f/t/h cervicasl degenerative chasnges most severe at C5-C6 with central canal narrowing without cord signal change and R>L neuroforaminal stenosis from C2-C6. MRI Brain revealed an incidental 1.0 cm R frontal dural based mass without local mass effect or sulcal effacement concerning for a meningioma. Prior to admission, patient was independent with mobility without use of AD and able to complete most of his ADLs. Patient states that he relies on grocery deliveries and uses Uber to access the comnmunity. Patient noted to have mild instability on feet with increased retropulsion without use of AD. Patient had significant improvements with overall stability and safety with use of FWW. Patient exhibited shuffling and at times, festinating gait pattern specifically with turns, requiring extra time to complete. Patient exhibited parkinsonism like deficits with activity and will benefit from outpatient follow up. Patient is safe to discharge home with home health PT and FWW provided at bedside.

• Currently in Pain
• Currently in Pain: No/denies
•  
• Physical Therapist Global Assessmenmt of Mobility Activity Achieved: Walking/Wheelchair 5-200ft with any level of assistance, with or without assist device.
•  
• Boston University AM-PAC "6 Clicks" Basic Mobility Outcome Measure
• Difficulty turning in bed without bedrails?: None (no difficulty)
• Difficultry standing up from chair?: A Little
• Difficulty lying on back to sitting on edge of flat bed?: None (no difficulty)
• Help needed moving to chair?: A Little
• Help needed walking in room?: A Little
• Help neweded climbing 3-5 stairs?: A Little
• AM-PAC Mobility 6 Clicks Score: 20
•  
• RECOMMENDATIONS
•  
• Physical Therapy Discharge Dispostion Recommendation: Home with HHPT
•  
• PT recommendations for mobilization with nursing: up ad lib
•  
• Assist Level: one person
•  
• Device: FWW
•  
• Patient's Current Functional Statuis Sufficient For PT Discharge Recommendation?: Yes
•  
• PP, PT
•  
• 8/22/2023
•  
• VL at 8/22/2023 5:25 AM

NEUROSURGERY HISTORY & PHYSICAL NOTE

History of Present Illness
81M hx of fibromyalgia and multiple prior cancers (colon/esophageal/prostate) p/w acutely worsened gait since 8/21 w/falling to the L side (no trauma prior to gait difficulties) f/t/h cervical degenerative changes most severe at C5-C6 with central canal narrowing without cord signal change and R>L neuroforaminal stenosis from C2-C6. MRI Brain revealed an incidental 1.0 cm R frontal dural based mass without local mass effect or sulcal effacement concerning for a meniongioma.

Per the patient, he had gait issues/balance issues prior to the fall which resulted in him falling. He denies any red flag symptoms. Says that all of his symptioms started on 8/21 acutely prior to the fall. His symptoms caused him to fall, not the other way around and these symptoms were not related to a traumatic event. Denies clumsiness w/hands or generalized weakness. Denies prior hx or spine surgery.

The patient notes no urinary/stool incontinence, numbness/tingling. Also denies any HA, N/V, chest pain, abdominal pain, shortness of breath, and visual/hearing changes.

No known recent history of using aspirin, Plavix, warfarin, Lovenox, Pradaxa/Xarelto/Eliquis, or any other anticoaqgulants/antiplatelet meedications.

• PMHx:
• Past Medical History:
• Diagnosis     Date
• * Adrenal adenoma     surveillance
• * Allergic state
• * Anemia
• * Blood transfusion without reported diagnosis
• * Cancer (CMS code) Colon
• * Chronic fatigue
• * Chronic fatigue syndrome
• * Complication of anesthesia
• * Depression
• * Elevated PSA
• * Fibromyalgia
• * GERD (gastroesophageal reflux disease)
• * Glucose intolerance (impaired glucose tolerance)
• * Hip fracture, left (CMS code) 9/2013
• * Hypercholesteremia
• * Osteopenia
• * Other mechanical complication of prosthetic joint implant 02/04/2015
• * Peyronie's disease
• * Polyp of colon
•   Last colonoscopy 2011, due every 2-3 years
• * Prostate disorder
•   Atypical cells on 3/2/2013 biopsy; repeat due 2/2014
• * Pseudoparasitic dysesthesias (CMS code) Water
• * Pure hypercholesterolemia
• * Renal insufficiency
• * Tremor

• Allergies
• Colesevelam, Pregabalin, and Tamsulosin
•  
• Medications
• (Not in a hospital admission)
•  
• FHx
• Family history nondontributory
•  
• SHx
• Sodial history noncontributory
•  
• ROS
• Per HPI
•  
• Vitals
• Temp: [36.8 °C (98.2 °F)-37 °C(98.6°F)] 36.8°C (98.2°F)
• Pulse: [75-106] 85
• *Resp: [16-18] 18
• BP: (122-139)/(64-79) 135/72
• SpO2: [94%-96%] 94%
•  
• Input/Output
• I/O last 2 completed shifts plus current shift
• iN, 1000[IV Piggyback: 1000]
• Out: 550[Urine: 550]
•  
• Physical Exam
• See below

Radiology Results

*MRI cervical spine without contrast

PRELIMINARY FINDINGS AND IMPRESSION:
BRAIN: No acute hemorrhage. No hemiation. Periventricular and deep white matter foci of T2/FLAIR signal hyperintensity, nonspecific, likely related to chronic microvascular ischemic change. No convincing evidence of any true reduced diffusion. Focal susceptibility signal in a region of FLAIR hyperintensity in the right centrum semiovale, most likely chronic microhemorrhage. Focal area of smooth dural thickening overlying the right frontal lobe measures up to 10 mm (series 600, image 441), is T1 isointense, mildly FLAIR hyperintense, and without abnormal susceptibility/reduced diffusion. There my be a thin posterior dural tail. Lesion is overall suggestive of a small meningioma without significant local mass effect. In retrospect this is visible on the recent companion CT brain but not on remote CT imaging from 2014. Ventricles within normal limits of size for age. No esxtra-axial collection. Maintained vascular flow voids.

CERVICAL SPINE: Multilevel cervical degenerative changes, including areas of disc osteophyte complex formation, uncovertebral hypertrophy, facet hypertrophy, and ligmentum flavum thickening, as suggested on CT. Ligamentum flavum thickening is mnore conspicuous on MRI, particularly at C5-C6. Findings are contributing to mild spinal canal narrowing at C3-C4, moderate to severe narrowing at C4-C5. severe narrowing at C5-C6, and moderate to severe narrowing at C7-T1. Mild deformity of the right lateral cord at C5-C6 due to external mass effect. No convincing evidence of any true cord signal abnormality. Degenerative neural foraminal narrowing, multilevel, is moderate to severe on the left at C2-C3, severe on the left at C3-C4 and C4-C5 (and moderate-to-severe on the right at C4-C5), and severe bilaterally at C5-C6. PRELIMINARY REPORT. FULL REPORT AND ADDITIONAL DETAILS TO FOLLOW.

XR Chest 1 View
Result Date: 8/21/2023
FINDINGS/IMPRESSION: Mild biapical scarring, lungs otherwise appear clear. No pleural effusion or pneumothorax. Unremarkable cardiac and mediastinal contours. Report dictated by: MV, MD, signed by: MVC, MD Department of Radioogy and Biomedical imaging.

1. No acute intracranial hemorrhage, hydrocephalus, or herniation.
2. No large vessel intracranial occlusion or significant arterial narrowing in the head or neck.
3. Multilevel cervical spondylosis, as described, with possibly severe narrowing of the bony spinal canal at C7-T1. The degree of bony canal stenosis is likely not significantly changed since 2015.
4. Findings possibly suggestive of right vocal cord paralysis; correlate with clinical symptoms.
//Noncontrast CT brain and CT angiography findings were discussed with Dr. G by BV, MD on 8/21/2023 at 1543 hours. Report dictated by BV, MD, signed by: XW, MD Department of Radiology and Biomedical Imaging.

PRELIMINARY FINDINGS AND IMPRESSION:
BRAIN: No acute hemorrhage. No herniation. Periventricular and deep white matter foci of T2/FLAIR signal hyperintensity, nonspecific, likely related to chronic microvascular ischemic change. No convincing evidence of any true reduced diffusion. Focal susceptibility signal in a region of FLAIR hyperintensity in the right centrum semiovale, most likely chronic microhemorrhage. Focal area of smooth dural thickening overlying the right frontal lobe measures up to 10 mm (series 600, image 441), is T1 isointense, mildly FLAIR hyperintense, and without abnormal susceptibility/reduced diffusion. There may be a thin posterior dural tail. Lesion is overall suggestive of a small meningioma without significant local mass effect. In retrospect this is visible on the recent companion CT brain but not on remote CT imaging from 2014. Ventricles within normal limits of size for age. No extra-axial collection. Maintained vascular flow voids.

CERVICAL SPINE: Multilevel cervical degenerative changes, including areas of disc osteophyte complex formation, uncovertebral hypertrophy, facet hypertrophy, and ligamentum flavum thickening, as suggested on CT. Ligamentum flavum thickening is more conspicuous on MRI, particularly at C5-C6. Findings are contributing to mild spinal canal narrowing at C3-C4, moderate to severe narrowing at C4-C5, severe narrowing at C5-C6, and moderate to severe narrowing at C7-T1. Mild deformity of the right lateral cord at C5-C6 due to external mass effect. No convincing evidence of any true cord signal abnormality. Degenerative neural foraminal narrowing, multilevel, is moderate to severe on the left at C2-C3, severe on the left at C3-C4 and C4-C5 (and moderate-to-severe on the right at C4-C5), and severe bilaterally at C5-C6. PRELIMINARY REPORT. FULL REPORT AND ADDITIONAL DETAILS TO FOLLOW

Assessment and Recommendations
[Patient tjr] 21155764 EDO2H/O2H

81M hx of fibromyalgia and multiple prior cancers (colon/esophageal/prostate) p/w acutely worsened gait since 8/21 w/falling to the L side (no trauma prior to gait difficulties) f/t/h cervical degenerative changea most severe at C5-C6 with central canal narrowing without cord signal change and R>L neuroforaminal stenosis from C2-C6. MRI Brain revealed an incidental 1.0 cm R frontal dural based mass without local mass effect or sulcal effacement concerning for a meningioma.
Exam: Aox3, EOMI, Face=, BUE/BLE 5/5, no hoffman's, no clonus, 2+ patellar reflexes. SILT, intention tremor present, exam w/component of rigidity.

• -ED Primary
• -Labs. Hgb 12.4. Plt 204, INR 1.1
• -PVR: pending
• Imaging:
• ---MRI Cervical Spine: as above
• ---MRI Brain: as above

• -As the patient is asymptomatic and is not myelopathic, the patient's gait abnormalities do not appear to be due to his cervical stenosis and rather would considerr a diagnosis such as parkinsonism as a more likely etiology of the gait abnormalities and fall.
• -Would recommend outpatient follow up with the neurosurgery spine clinic for this stenosis if he becomes symptomatic.
• -No acute neurosurgical intervention indicated at this time for the spine or the incidental meningioma.
• -Recommend outpt follow up in spine clinic with Dr. T.
•  
• Discussed with Dr. T and Dr. A.
•  
• Please page neurosurgery with questions: [--- ----]

ED Triage Notes

• Medical Screening Exam

•  
• Seen by KHC, PA-C
• Date: 8/21/2023
•  
• This MSE note is a preliminary screening to initiate workup and test ordering.
• Chief Compatlaint/History:
• No chief complaint on file.
•  
• Loss of balance at 12am today and fell injuring lower ribs.
• No shortness of breath
• Still feels off balance and having trouble walking
•  
• Review of Systems:
• Denies fever

Physical Exam

• General Awake and alert
• Skin: Warm, dry
• Symmetric face; no dymetric ggaul grips, normal heel to shin, unable to stand independently, unable to walk

MSE differential diagnosis;

• Multiple differential diaganosis considered incdluding, however not limited to TIA, CVA, vertigo, dehydration, infection
• My MSE plan includes:
• Testing as ordeered.
• Supportive care as ordered.

Significant Event

CODE STROKE NOTE

• Patient Location: Emergency Department
•  
• ED Arrival Date: 8/21/23
• ED Arrival Time: 1507
•  
• Date Code Stroke Call Placed: 08/21/23
• Time Code Stroke Call Placed: 1525
•  
• Date Neuro Resident Arrived: 08/21/2023
• Neuro Resident Arrived: 1528
•  
• Working diagnosis (choose ALL that apply); Uncertain
•  
• Date patient was last seen well: 08/21/2023
• Timr patient was last seen well: 0000
•  
• Initial NIH Stroke Scale:
• Level of Consciousness: 0
• LOC Questions: 0
• LOC Commands: 0
• Best Gaze: 0
• Visual: 0
• Facial Palsy: 0
• Motor Arm, Left: 0
• Motor Arm, Right: 0
• Motor Leg, Left: 0
• Motor Leg, Right: 0
• Limb Ataxia: 0
• Sensory: 0
• Best Language: 0
• Dysarthria: 0
• Extinction and Inattention: 0
• TOTAL (NIH Stroke Scale): 0
• (08/21/2023 1534: KPI, MD

• Was IV stroke thrombolysis administered at UCSF? No
• Reason for no IV tPA (choose ALL that apply):: Outside of time window for IV tPA
•  
• Time of IV tPA infusion:
• N/A
•  
• ED Door-to Needle Time:
• N/A
•  
• Was patient sent to neuroangiography suite? No
•  
• Signed: KPI, MD
• Date: 8/21/23

• Interdisciplinary

• HD at 8/22/2023 12:14 PM

CASE MANAGEMENT DISCHARGE

•  
• CASE MANAGEMENT DISCHARGE (most recent)
•  
• Discharge Note Flowsheet - 08/21/23

• Contact information for after-discharge care
•  
• Home Medical Care
•  
• CARE IN TOUCH HOME HEALTH AGENCY
• 41829 ALBRAE STREET, SUITE 112
• FREMONT CA 94538
• Phone: 650-255-3958
• Care in Touch is reaching out to obtgfain authorization from the pt's insurance. Final HHPT order sent in AS.
•  
• HD BSN, RN
• Case Management Supervisor
• VOALTE
• O: 415-476-6147
• C: 415-203-9360
•  
• HD at 8/22/2023 12:11 PM
•  

CASE MANAGEMENT ASSESSMENT

• Screening
• Any anticipated barriers to discharge? No
• Does patient have any discharge planning needs? Yes
•  
• Adult Assessment
• Transfer from outside fadility: No
• Does the Patient have a PCP? Yes
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• Caregiver and Family Support
• CM Assessment completed with: Patient
• Patient/Parent/Legal Guardian is Decision Maker: Yes
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• Living Arrangements and Services
• *Who does the patient live with? Alone
• *Patient's Current Residence: Apartment/House
• Address Type: Permanent
• Residential Access: Wheelchair access
• *Support Systems: Friends/Neighgbors
• *Current Services in Place: DME
• Current DME: Cane, Front-wheeled walker

• Functional Status
• Prior ADLs: Needs Assistance
• Transfers (prior): Needs Assistance
• Bathing/Showering (prior): Needs Assistance
• Toileting (prior): Needs Assistance
• Current ADLs" Needs Assistance
• Ambulation (current) Needs Assistance
• Prior Mental Status: Alert, oriented
• Current Mental Status: Alert, oriented

• Proposed Discharge Plan
• Proposed Discharge Plan: Home with services
• Home Discharge Destination: Facesheet addres
• Anticipated Skilled or Acute needs: Physical Therapy
• Proposed Transportation Arrangements: Self/Family/Caregiver (no assistance needed)
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• CM discussed Home Health services for HHPT based on PT recommendation. Pt is agreeable. Per patient he will take a Lyft ride home.
• HD BSN, RN

• Case Management Supervisor
• VOLTE
• O: --- --- ----
• C: --- --- ----

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