Patient’s Personal Presentation and Emotional Tone
Mrs. Carter is well groomed and in no acute distress, but she and her husband are quite concerned about what she is experiencing. She is feeling slightly depressed.
Patient is a poor historian, husband supplying details
Presenting Problem and History of the Present Illness
Mrs. Carter had a similar and briefer episode a few weeks previously, but she thought she would wait until her regular appointment next month. This morning, she experienced slight difficulty speaking and some clumsiness of her right hand, which caused her to drop a cup. The symptoms improved for an hour or so and then began to reoccur. In the office she exhibited hesitancy and slurring of speech, inability to elicit some words, and she was unable to get a tissue out of her purse with her right hand because of weakness of her entire right upper extremity. She reports intermittent coughing when she drinks liquids. She did not complain of pain or other discomfort.
Past Medical History
Hypertension, under variable control, for 20 years. Type 2 diabetes mellitus controlled by diet.
Elevated total cholesterol and LDL and low HDL.
Past Surgical History
Past Psychiatric History
Propranolol extended release, 80 mg. daily Hydrochlorothiazide 12.5 mg. Daily
No known drug allergies (NKDA).
Family Medical History
Father died at age 72 from stroke. Mother died at age 78 from heart problems.
A sister, age 68 and a brother, age 66, are living. The sister has high blood pressure, and the brother has diabetes. A maternal uncle had diabetes.
Mrs. Carter has been married for 51 years and has three children, a son age 42, daughter age 47, and a son age 49. All are thought to be in good health. She has a good relationship with her husband and keeps in close contact with her daughter and fairly close contact with her sons. She graduated college and taught elementary school for 30 years. Her husband is a retired businessman. She has never smoked and drinks 1-2 glasses of wine per week. She denies illicit drug use. She generally eats a balanced diet, but she has a predilection for fried foods and finds them hard to resist.
Review of Systems
General: She generally maintains a good mood. She has been moderately overweight for the past 10 to 15 years. BMI 31
HEENT: She has had occasional headaches that have responded to aspirin or acetaminophen. She wears glasses for reading and has had difficulty seeing from her “right eye” since the onset of her current symptoms. She has no problem with hearing. Reports occasional difficulty swallowing water.
Cardiovascular: She has no history of heart attack or palpitations. She has had hypertension that has been variably controlled on medications.
Respiratory: No shortness of breath and no difficulty lying flat.
Gastrointestinal: No problem with heartburn, nausea or constipation.
Genitourinary: No urgency or dysuria, has some problem with frequency.
Reproductive: G-3, P-3, Ab-0. Postmenopausal.
Endocrine: Has diabetes, diagnosed about 20 years ago.
Musculoskeletal: Occasional joint pain and stiffness and occasional backache.
Neurological: See presenting problem. No similar problem in past.
Psychiatric: No history of depression or anxiety problems.
Blood Pressure: 180/100 mmHg Pulse: 90/min.
Respiratory Rate: 24/min. Temperature: 98.6º Fahrenheit Height: 5” 4” Weight: 180 lbs. BMI: 31
General: alert and oriented to person and place but not time (month incorrect)
HEENT: No cataracts, optic discs flat, hearing intact, normal cough.
Pulmonary: Lungs clear to percussion and auscultation.
Cardiac: Regular rhythm without murmurs. Mild tachycardia.
Abdomen: Flat, soft, without tenderness, normal bowel sounds.
Pelvic: Not done at this time. Normal in recent past.
Neurologic: Alert and cooperative. Speech is slurred, and she has difficulty expressing herself verbally. Appears to understand what is said to her. Unable to see to right visual field out of either eye (right homonymous hemianopia) right visual field deficit, weakness of right lower face, weakness on right side with arm more involved than leg. Sensation intact to pin. DTR’s 2+ on left and 3+ on right. Right extensor plantar response (Babinski).
Extremities: No deformities or swelling.
EKG: WNL except for tachycardia.
Chest x-ray: WNL
Cholesterol: Elevated LDL: Elevated HDL: Elevated Triglycerides