130959255
FIH
1431063
10119/hy66
738478
6/15/1994 12:00:00 AM
RIGHT OCCIPITAL HEMORRHAGIC STROKE .
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
6-15-94
DISCHARGE DATE :
6-26-94
PRINCIPAL DIAGNOSIS :
Right occipital hemorrhagic stroke .
HISTORY OF PRESENT ILLNESS :
Ms. Tlandkotesmitskote is a patient who came complaining of feeling dizzy and bumping into objects on her left side .
She is a seventy-one year old female with a history of hypertension who is in otherwise good health .
This morning while on a cruise ship , she was eating breakfast when she suddenly noticed she could not see a roll on her plate although she knew that it was there .
She also felt dizzy and the room was spinning .
While walking , she kept bumping into object on her left side .
She also complained of a dull , right sided headache over the right eyebrow .
Symptoms lasted about five hours and then gradually resolved except for the change in vision .
She denied having any weakness , numbness , or pain .
She also denies having hoarseness , difficulties in finding words , speaking , hiccups , or diplopia .
PAST MEDICAL HISTORY :
The past medical history is significant for hypertension .
The past surgical history is negative .
MEDICATIONS ON ADMISSION :
Atenolol , 25 mg PO qd .
ALLERGIES :
The patient has no known drug allergies .
REVIEW OF SYSTEMS :
On review of systems , the patient denied any history of transient ischemic attacks .
FAMILY HISTORY :
Father and mother died in their eighties of heart disease .
SOCIAL HISTORY :
The patient denied using tobacco .
PHYSICAL EXAMINATION :
On physical examination , she was a very pleasant , moderately obese female in no apparent distress .
She was afebrile and her vital signs were stable .
The head was normocephalic and atraumatic .
The pupils were equal , round , reactive to light .
The tympanic membranes were gray .
The fundi were sharp .
The neck was supple with full range of movement .
The lungs were clear to auscultation bilaterally , without rales or wheezes .
The heart had a recovery regular rate and rhythm .
The abdomen was soft , nontender , nondistended .
Extremities revealed 2+ pitting edema in the knees bilaterally .
The neurological examination revealed that the patient was awake , alert and oriented to person , place and time .
She was able to subtract serial sevens , remember three out of three objects after five minutes , and there was notable aphasia or word finding difficulty .
The cranial nerves showed pupils were bilaterally active from 3 to 2 mm .
There was a dense hemianopsia on the left side .
The extra ocular muscles were intact bilaterally .
Corneals were present bilaterally .
Sensation was intact to light touch and pin prick bilaterally .
Face was symmetric .
Eye closing was tight .
Hearing was intact bilaterally .
Palate was midline .
Gag was intact .
The sternocleidomastoid and trapezius had good strength .
Tongue was midline .
Strength was 5/5 in bilateral upper extremities and bilateral lower extremities in detail .
There was no pronator drift .
Sensation was intact to light touch , pin prick , and proprioception .
Cerebellar examination revealed in intention tremor on the right side .
The patient had considerable difficulty with left finger-to-nose movement , most likely secondary to hemianopsia .
There was no nystagmus , except for some fine fast beat nystagmus bilateral extremes of abduction .
Reflexes were symmetric and 2+ bilaterally at the biceps tendon , 2+ bilaterally at brachial radialis , 2+ bilaterally at the patellar tendon , 1+ bilaterally Achilles tendon .
The toes were downgoing bilaterally .
Gait :
patient had difficulty with tandem gait and fell forward while standing on his his toes .
Otherwise , the gait was normal .
LABORATORY DATA :
Laboratory studies on admission demonstrated a sodium of 144 , potassium 4.1 , chloride 106 , bicarbonate 20.0 , BUN and creatinine 12/0.7 , glucose 99 , white blood count of 5.7 , hematocrit of 40.6 , platelet count of 226 , prothrombin time was 9.4 , partial thromboplastin time was 29 .
The computerized tomography scan was performed and showed a right occipital hemorrhage .
SUMMARY :
The patient is a seventy-one year old female with a history of hypertension who now presents with a right occipital hemorrhagic stroke .
HOSPITAL COURSE :
The patient was admitted to the hospital for further evaluation and work up .
The patient was admitted to the Intermediate Care Unit in the Neurology Intensive Care Unit .
However , she was soon moved out of there as her examination appeared to be stable .
A Neurosurgery Service consultation was obtained and they felt that no surgical intervention was required .
The patient underwent a number of tests .
She had a magnetic resonance imaging study and magnetic resonance imaging angiogram performed which showed a large hemorrhagic lesion on the occipital lobe .
There was no clear enhancing mass , but follow up was suggested .
So an magnetic resonance imaging angiogram was obtained and showed the right parietal occipital hemorrhage .
The MRA showed mild narrowing of the left ICA just distal to the bifurcation .
There was also scattered T2 hyperintense foci within the periventricular and left frontal white matter consistent with small vessel disease , gliosis or demyelination .
A Holter monitor was obtained and showed that the patient was in normal sinus rhythm .
The heart rate was 53 to 106 .
There were some very rare atrial premature contractions .
There were no ventricular premature contractions .
An echocardiogram was obtained and showed that the ejection fraction was 60% and there was no thrombus .
It was felt to be within normal limits .
Over the ensuing days , the patient had several episodes of confusion at night .
However , these gradually resolved .
She also developed what appeared to be urinary tract infection and was placed on PO Bactrim .
By 6-26-94 , the patient was felt to be ready for discharge .
At that time , she was afebrile and her vital signs were stable .
She was tolerating a regular diet .
She was awake , alert and oriented to person , place , and time .
She continued to have a dense left hemianopsia , but otherwise was neurologically intact .
The patient was discharged home with Santea Gehawhi General Hospital care and instructed to follow up .
MEDICATIONS ON DISCHARGE :
The patient was discharged on Tenormin , 25 mg PO qd ; Bactrim DS , one PO bid x5 days .
TATAJO SEE , M.D.
TR :
ba / bmot
DD :
8-4-94
TD :
08/06/94
CC :