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{{CMG}}; {{AE}}
{{CMG}}; {{AE}}
{| class="wikitable"
!Site
!Patient
!AE
!Complication
!Event date
!AE code
|-
|00007
|L003/ZZK
|0
|TIA
|mm/dd/YYYY
|xxx
|}


== Demographic / Medical history ==
== Demographic / Medical history ==
* '''Demographic''': 77, M
* '''Demographic''': 77, M
* '''Past Medical History:''' HTN, CAD w CABG, MI, AVR  
* '''Past Medical History:''' HTN, BPH, CAD w CABG, MI, AVR  
* '''Past Surgical History:'''  
* '''Past Surgical History:'''  
** AVR (#25 magna ease valve) on 12/14/17
** AVR (#25 magna ease valve) on 12/14/17
Line 28: Line 12:
** Appendectomy in 1957
** Appendectomy in 1957


* '''Medications:''' [relevant to the event not all]
* '''Medications:'''  
** Metoprolol
** DAPT
** Tamsulosin


== Procedure ==
== Procedure ==
Line 43: Line 30:


* '''Event summary''':
* '''Event summary''':
** Symptoms and sign: Subject presented 1. Right leg collapse,  
** Symptoms and sign: Subject presented with
2. Right arm and right leg weakness
*** Right leg collapse,  
** Episodes last ~ 2 -10 minutes, beginning from 1 to 3-4/day  
*** Right arm and right leg weakness  
** No visual or speech difficulties, no headache or neck pain
** Episodes lasted approximately  2 -10 minutes and ranged from 1-4/day  
** No visual or speech difficulties, no headache or neck pain  
** No history of vertigo, syncope, loss of consciousness or seizures  
** No history of vertigo, syncope, loss of consciousness or seizures  
** Other important symptoms related to the chief complaint.
** Other important symptoms related to the chief complaint.
Line 53: Line 41:
*** BP: 124/66  
*** BP: 124/66  
*** HR: 96  
*** HR: 96  
'''Event (2):'''
*'''Site Reported Event Onset Date:''' mm/dd/YYYY
* '''Event summary''':
** Symptoms and sign: Subject presented with [sign and symptom] on mm/dd/YYYY.
** Important characteristics of the chief complaint such as severity, site, and duration.
** Other important symptoms related to the chief compliant.
** Physical assessment:
*** Vital signs
*** Positive physical examinations or related negative examinations.
== Laboratory data ==
== Laboratory data ==
* '''Lab studies list: ('''Date/ name/ value)
* '''Lab studies list: ('''Date/ name/ value)
** 01/04/2018 / HDLC / 31
** 01/03/2018 / INR / 1.2


== Diagnostic tests ==
== Diagnostic tests ==
* mm/dd/YYYY at xx:xx on brain MRI
* 01/03/2018 '''TTE'''
* mm/dd/YYYY at xx:xx on MRA
** Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
* mm/dd/YYYY at xx:xx on CT
** Moderate left atrial enlargement
* mm/dd/YYYY at xx:xx on EEG
** Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
* mm/dd/YYYY at xx:xx on Carotid US
* 01/03/2018 '''MR Brain'''
* mm/dd/YYYY at xx:xx on ECG:
** NO evidence of vascular occlusion
 
** No evidence of restricted diffusion to suggest infarction
* mm/dd/YYYY at xx:xx on ECHO:
* 01/03/2018 '''MRA H/N'''
* mm/dd/YYYY at xx:xx on Ultrasound:
** Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
* mm/dd/YYYY at xx:xx on Endoscopy:
* 01/03/2018 '''Carotid US(Preliminary)'''
* mm/dd/YYYY at xx:xx ... (Other relevant imaging and diagnostic tests)
** Right: 1-49% stenosis of right internal carotid
** Left: 1-49% stenosis of left internal carotid
** Bilateral vrtebral arteries patent with antegrade flow
* 01/03/2018 '''EEG'''
** Normal awake EEG
** No epilitiform discharges, focal changes or other abnormalities
==Consults==
==Consults==
*Neurology consult : 01/03/2018
*Recommendations:
**CBC,CMP
**Admission to neurology service
**MRI brain with or without contrast
**MRA of the extracranial and intracranial circulation
**Carotid duplex US
**EEG
*Date and time of consult
*Date and time of consult
*Suggested treatments
*Suggested treatments:
**Aspirin 81mg chew tab
**Clopidogrel 75 mg tab
**Enoxaparin 40mg inj
**Metoprolol succinate 25mg extended release
==Clinical course==
==Clinical course==
*
*Date and time of events,
*Date and time of events,
*Patient condition got worse or better.
*Patient condition got worse or better.
==Treatment and outcome==
==Treatment and outcome==
*List of relevant medical treatments
*List of relevant medical treatments
*Out come [Discharge / Hospice / Death]
**Aspirin 81mg chew tab
**Clopidogrel 75 mg tab
**Enoxaparin 40mg inj
**Metoprolol succinate 25mg extended release
*Out come - Discharged home

Latest revision as of 16:44, 18 June 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Demographic / Medical history

  • Demographic: 77, M
  • Past Medical History: HTN, BPH, CAD w CABG, MI, AVR
  • Past Surgical History:
    • AVR (#25 magna ease valve) on 12/14/17
    • Stent on 10/10/2017
    • CABG in 2007
    • Appendectomy in 1957
  • Medications:
    • Metoprolol
    • DAPT
    • Tamsulosin

Procedure

  • Index Procedure Date/Time:
    • mm/dd/YYYY at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Access site details
    • The site reported that there were/were not procedural complication(s).

Event(s)

Event (1):

  • Site Reported Event Onset Date: 12/26/2017
  • Event summary:
    • Symptoms and sign: Subject presented with
      • Right leg collapse,
      • Right arm and right leg weakness
    • Episodes lasted approximately 2 -10 minutes and ranged from 1-4/day
    • No visual or speech difficulties, no headache or neck pain
    • No history of vertigo, syncope, loss of consciousness or seizures
    • Other important symptoms related to the chief complaint.
    • Physical assessment:
      • Normal neurological exam
      • BP: 124/66
      • HR: 96

Laboratory data

  • Lab studies list: (Date/ name/ value)
    • 01/04/2018 / HDLC / 31
    • 01/03/2018 / INR / 1.2

Diagnostic tests

  • 01/03/2018 TTE
    • Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
    • Moderate left atrial enlargement
    • Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
  • 01/03/2018 MR Brain
    • NO evidence of vascular occlusion
    • No evidence of restricted diffusion to suggest infarction
  • 01/03/2018 MRA H/N
    • Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
  • 01/03/2018 Carotid US(Preliminary)
    • Right: 1-49% stenosis of right internal carotid
    • Left: 1-49% stenosis of left internal carotid
    • Bilateral vrtebral arteries patent with antegrade flow
  • 01/03/2018 EEG
    • Normal awake EEG
    • No epilitiform discharges, focal changes or other abnormalities

Consults

  • Neurology consult : 01/03/2018
  • Recommendations:
    • CBC,CMP
    • Admission to neurology service
    • MRI brain with or without contrast
    • MRA of the extracranial and intracranial circulation
    • Carotid duplex US
    • EEG
  • Date and time of consult
  • Suggested treatments:
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release
  • Out come - Discharged home
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