156406283
HLGMC
7213645
64723/51cy
5/28/1993 12:00:00 AM
Discharge Summary
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
5-28-93
DISCHARGE DATE :
6-4-93
HISTORY OF PRESENT ILLNESS :
The patient is a 58 year old right hand dominant white male with a long history of hypertension , changed his medications from Aldomet to Clonidine six weeks ago .
The patient has a history of adult onset diabetes mellitus , ankylosing spondylitis , status post myocardial infarction in '96 ( ? ) now with acute onset of left face and arm greater than leg hemiplegia and primary hemisensory loss on the left .
Briefly , he was talking to a friend at 5:30 p.m. the day prior to admission , when he had to grab his locker and sit down .
His voice became slurred and he had a mild central dull headache .
He was unable to move the left side of his body and felt numb on that side .
He was taken to Wayskemedcalltown Talmi and transferred to Heaonboburg Linpack Grant Medical Center with a computerized tomography scan showing a 1x2 thalamic capsular hemorrhage without superficial mass effect .
His blood pressure was 220/110 there .
He denies any visual symptoms or cortical-type symptoms .
He is a heavy smoker and drinks 2-3 shots per day at times .
MEDICATIONS ON ADMISSION :
Vasotec 40 mg q.day , Soma 1 tablet q.day , Demerolprn , Clonidine .
ALLERGIES :
The patient has no known drug allergies .
PAST MEDICAL HISTORY :
As described above .
FAMILY HISTORY :
The family history is positive for diabetes mellitus , positive for cancer .
SOCIAL HISTORY :
The patient lives with two people in Cinglendda .
PHYSICAL EXAMINATION :
On physical examination , patient is in no acute distress , afebrile , blood pressure 134/80 , heart rate 80 and regular , no bruits .
Cardiovascular exam :
regular rate and rhythm with a I/VI systolic ejection murmur .
His lungs were clear to auscultation and percussion .
The abdomen was soft and non-tender , obese , with normal bowel sounds .
Back and neck were stiff and sore , without localizing tenderness .
On neurological examination , mental status alert and oriented x three , good memory , fluent speech , good repetition and naming .
Able to describe two routes from house to the CMH .
The cranial nerves showed full visual fields without extinction , pupils 5 to 3 bilaterally and equal , disks flat , lower left facial decreased sensation to temperature , pin prick on the left V1 through V3 , tongue deviates to the left , good gag , decreased shrug on the left .
Motor examination showed full power on the right arm and leg , could barely flex fingers of the left hand , pulls left arm medially only .
Left leg could flex 2/5 and wiggle toes .
On sensory examination , had decreased pin prick , temperature , vibration in the left side of the body .
The finger-to-nose was okay on the right .
On reflex examination , 2 on the right upper extremity , 2+ on the left upper extremity , 2 on the right knee , 0 on the right ankle , with down going toe on the right .
Three on the left knee , 4 on the left ankle with upgoing toe and clonus on the left .
LABORATORY DATA :
Electrolytes were within normal limits , glucose 192 , BUN and creatinine 9/0.7 , hematocrit 49.5 , white blood count 7.9 , platelet count 166,000 , 65% polys , 3 bands , 24% lymphs .
The electrocardiogram showed normal sinus rhythm with old Q wave inferior myocardial infarction .
Head computerized tomography scan showed 1.5 to 2 centimeter bleed in the right thalamus extending to the internal capsule with mild distortion only , no shift .
The chest X-ray was clear .
HOSPITAL COURSE :
The patient was admitted to the floor for observation .
The neurological examination on discharge was no movement in the hand on the left or arm .
Slight abductive and adductive movement on the left only in the upper extremity .
On the lower extremity , could wiggle toes , flexor and plantar , 3+/5 , quadriceps 4/5 on the left .
2. hypertension .
The patient was managed with Vasotec , Nifedipine and Clonidine with blood pressure under good control at the time of discharge , average 125 systolic , 70 diastolic , heart rate of 72 .
Also managed with Valium 5 mg PO t.i.d.
Muscle spasms were managed with Flexeril 10 PO t.i.d.
3. diabetes mellitus .
The patient was started on 2.5 of Micronase with resulting sugars as low as 63 , decreased to 1.25 mg q.day .
The patient is discharged in fair condition with medical approval to the Pasi .
MEDICATIONS ON DISCHARGE :
Vasotec 20 mg PO b.i.d. , Clonidine 0.2 mg PO b.i.d. , Nifedipine 20 mg PO t.i.d. , Flexeril 10 mg PO t.i.d. , Valium 5 mg PO t.i.d. , Micronase 1.25 mg q.day .
ADVERSE DRUG REACTIONS :
The patient was found to be allergic to Percocet and Percodan during his hospital course .
DISCHARGE DIAGNOSIS :
Right thalamic hemorrhage , hypertension , diabetes mellitus .
ROBTHER TIMES , M.D.
DICTATING FOR :
SHAA LEFT , M.D.
TR :
nj / bmot
DD :
6-4-93
TD :
06/04/93
CC :
Dr. Namarce Aldridge Pasi STAT