Sandbox:ssw 2
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Site | Patient | AE | Complication | Event date | AE code |
---|---|---|---|---|---|
00007 | L003/ZZK | 0 | TIA | 12/26/2017 | 307 |
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 1. Right leg collapse,
2. Right arm and right leg weakness
- Episodes last ~ 2 -10 minutes, beginning from 1 to 3-4/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
- Out come [Discharge / Hospice / Death]