Medical Case Study: Chief Complaint

Decent Essays
Chief Complaint
Followup of CVA and diabetic third nerve palsy.

History
Patient is a 57-year-old left-handed white male who presents with his wife for followup of two recent hospitalizations. He was initially hospitalized at July 25, 2015, when he went to bed feeling fine and got up at four in the morning and noted that there was something wrong with his left foot. He thought maybe he slept on it wrong. He went back to bed, but when he woke up again, it was still a problem. He did present to the emergency room for that. He had a recent NSTEMI about one month ago for which he had stents and was sent off Effient and aspirin. On neurological exam done by Dr. [____] that day, his extraocular muscles were normal. He had normal facial symmetry,
…show more content…
I thought possibly it was small vessel disease. In either case, we agreed to start this person on aspirin and Plavix, which he complied with. He was readmitted on July 29th, due to significant diplopia. It was worse when he was looking to the right. His left eye did not adduct past the midline. In the differential, besides recurrent stroke, was diabetic partial third nerve palsy. His followup MRI was negative. He did see ophthalmology, Dr. [____], who found that he had an isolated left medial rectus palsy, thought due to a diabetic partial third nerve. The day after that evaluation, he was significantly improved and was discharged to home, since he has been out, he has notes very little problems with his extraocular muscles. He notes that when he looks to the right, it takes a little longer for him to focus and if he looks very far to the right, he does have slight diplopia. He did see ophthalmology in followup and states that the doctor was very pleased with his amount of progress. He did have slightly increased intraocular pressure. He does have a past history of glaucoma, for which he had undergone laser surgery over 15 years ago. He is getting PT, OT, and speech therapy. …show more content…
Past Medical History
Positive for coronary artery disease, status post recent NSTEMI with PTCA and stenting.
Diabetes mellitus, poorly controlled, recently put on new medications.
Hypertension.
Chronic kidney disease.
Recent right thalamic infarct with small vessel ischemic disease.
Glaucoma with laser surgery 15 years ago, slowly worsening.
Appendectomy.
Medications
Plavix 75 mg, amlodipine 5 mg, losartan 50 mg, Lopressor 25 mg b.i.d., Crestor 10 mg, Ativan 0.5 mg every 6 hours p.r.n. anxiety, which he does not take, aspirin 81 mg, lysine 1000 mg b.i.d, Zantac 150 mg daily, Glynase 3 mg b.i.d., Levemir 24 units subcutaneous daily, Byetta 5 mcg b.i.d., vitamin D3 1000 units a day, folic acid one tablet a day.

Allergies
Pistachio, walnuts, tape, lisinopril, penicillin G, atorvastatin.

Social History
He does not smoke or drink. He is married. He is an EMT.

Family History
Positive for heart disease and diabetes.

Physical Examination
Constitutional
Weight 204 pounds. Height 6". Respiration 12. Pulse

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