Report #2852432

Received Aug 3, 2025

Life-threateningHospitalizedER / ED visitOffice visitDisabled

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Overview

Sex: Male
Age: 77 yrs
State: CA
Recovered: Not recovered
Vaccinated: Jul 18, 2025
Onset: Jul 21, 2025
Days to onset: 3
Hospital days: 9

Vaccines (2)

Type	Name	Manufacturer	Dose	Lot	Route / Site
COVID19	COVID19 (COVID19 (PFIZER-BIONTECH))	PFIZER\BIONTECH	6	MD3414	IM / RA
VARZOS	ZOSTER (SHINGRIX)	GLAXOSMITHKLINE BIOLOGICALS	1	2HJ99	IM / LA

Symptoms (18)

Angiogram cerebral abnormalBrain oedemaCarotid artery stenosisCerebral artery occlusionCerebral infarctionComputerised tomogram head abnormalDysarthriaExtensor plantar responseEye movement disorderFacial paresisHemianopiaHemiparesisMagnetic resonance imagingMiddle cerebral artery strokeNeurologic neglect syndromeReflexes abnormalSensory lossVertebral artery stenosis

Symptom narrative

Dysarthria. Can answer simple questions. Left facial weakness, dense right gaze preference and left field cut vs neglect. Right side 5/5, left with dense hemiparesis. Reflexes brisker on the left and left plantr response is extensor. Patient does not recognize his left hand and has absent sensation to temperature and vibration on the left. NIHSS 23 CT shows early infarct of most of right hemisphere sparing right aca territory CTA shows occlusion of right mca Also left vertebral artery and has intracranial stenosis of both ica's Impression: patient with large right mca stroke with dense left hemiparesis and early cerebral edema.

Current illness

dizziness

Medical history

HTN, BPH, parkinsons wo dyskinesia wo fluctuations, diverticulosis of colon, elevated PSA

Other medications

carbidopa-levodopa (sinemet) 25-100mg TID, amlodipine (norvasc) 10mg daily

Allergies

NKDA

Lab data

CT, MRI