Use the sample attached to create a Health History paper
History of Health/ Present Illness:
Previous CVA in September 2019 (MRI w/ and w/o contrast: acute lacunar strokes in anterior basal ganglia and internal capsule on left and in the left central pons; nonspecific small area of enhancement in right basal ganglia possibly from subacute strokes; old encephalomalcic changes in both frontal lobes. Bilateral carotid u/s: negative- no atherosclerosis plaque in either bifurcation region. On d/c she was started on baby aspirin 2x per day; since was discontinued by patient), residual weakness, requires use of cane for ambulation, chronic uncontrolled hypertension (currently untreated), hyperlipidemia; untreated due to medication noncompliance (last fasting lipid panel in 01/2019; total cholesterol at 178, triglycerides at 127, HDL at 42, LDL at 111), DM type 2: diet controlled. Last HbA1c in 01/2019 at 5.7. Seizure disorder, previous EEG done at initial presentation of seizure event demonstrated right sided frontotemporal slowing and spiked discharges. Patient was found by husband approximately 0400, patient was laying on the couch, unable to stand, respond appropriately to questioning or speak coherently. Husband stated the room was in disarray, possibly from a fall. He also reports possible urinary incontinence with wet spot on the couch by the patient. Patient presented to ED with right upper and lower extremity weakness, slurred, speech and disorientation. Patient was unable to recall most of the night’s events, but states she fell on her buttocks. Patient also stated that she felt like she was speaking weirdly although she knew what she wanted to say. Husband reports that the right sided extremity weakness is considerably worse in regards to LE strength and ambulation. Patient admits to significant cocaine use and medication noncompliance since June 2019. Patient denies head trauma, headache, change in vision, n/v, dizziness, SOB, chest pain, or palpitations.