194442600 RWH
1642008
83328/rh01
61509
10/19/1993 12:00:00 AM
RIGHT CAPSULAR PUTAMENAL HEMORRHAGE .
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
10/19/93
DISCHARGE DATE :
10/25/93
PRINCIPAL DIAGNOSIS :
Right capsular putamenal hemorrhage .
ASSOCIATED DIAGNOSIS :
hypertension .
HISTORY OF PRESENT ILLNESS :
Mrs. Dua is a 34 year old white female with an unclear history of hypertension for at least five years .
She was in her usual state of health until around 12:40 on October 19 , when while on the phone , started to have difficulty in talking .
Her speech became slurred , this was followed a few seconds after by weakness and numbness of her arm and leg .
She did not complain of headache , diplopia , or any other neurological symptoms .
She was seen at A Memorial Hospital where her blood pressure was measured at 240/120 and was found to have a mild left hemiparesis .
She was then transferred to Ro Woodma Healthcare for further management .
PAST MEDICAL HISTORY :
negative .
HABITS :
She does not smoke , does not use birth control pills , does not use drugs .
Denies any abuse of alcohol .
FAMILY HISTORY :
Father and brother died of PE .
REVIEW OF SYSTEMS :
negative .
SOCIAL HISTORY :
She works at TackyMart , is single .
PHYSICAL EXAMINATION :
A 34 year old white female lying in bed , anxious ; blood pressure of 220/120 , afebrile .
Skin :
no lesions .
HEENT :
normocephalic , atraumatic , anicteric .
Neck :
supple , no bruits .
Heart :
regular rhythm with no murmur , rub or gallop .
Lungs :
clear to auscultation .
Abdomen :
bowel sounds present , soft , nontender , nondistended , guaiac negative , no hepatosplenomegaly .
Extremities :
no clubbing , cyanosis or edema .
Neurological :
she was alert and oriented times three .
Her speech was fluent with no phasic or praxic problems , dysarthric .
Memory and attention span good .
Visual fields were full to confrontation .
Fundi were flat .
Pupils were 2 millimeters down to 1 millimeter by direct and consensual stimuli .
Extra ocular movements were full .
Corneals diminished on the left side .
V1 through V3 , diminished light touch and pinprick in the left side .
There was a left central facial paresis .
Gag was symmetric .
Tongue deviated to the left .
There was a left arm pronator .
The ______________ was normal .
Strength was 5/5 on the right side , 4/5 on the left side .
The deep tendon reflexes were 2+ on the left side , 1+ on the right side .
The plantar was upgoing on the left side .
On sensory exam there was a mild diminution of light touch , pinprick , position , and vibration sense in the left side .
Cerebella :
the fine motor movements of the left hand were diminished , there was a mild dysmetria on the left side to finger / nose and heel / shin .
The walk was paretic in the left side .
LABORATORY DATA :
sodium 140 , potassium 4 , chloride 107 , CO2 25.4 , BUN 9 , creatinine .8 , blood sugar 130 .
Uric acid 4.7 , cholesterol 150 , triglycerides 74 , HDL 44 , LDL 91 .
Normal liver function tests .
Urine and serum toxicology screen negative .
Thyroid stimulation hormone 1.9 .
Dexamethasone suppression test negative with a cortisol level at 8 a.m. of 1.7 .
Twenty-four urine for catecholamine , metanephrines , and VMA pending at the time of discharge .
White blood cell count 9.8 , hematocrit 44.1 , platelets 262 , prothrombin time 10.4/ 10.3 , partial thromboplastin time 25.9 .
urinalysis :
specific gravity 125 , PH 6 .
Urine culture negative .
Sedimentation rate 2 , antithrombin 3 .
Protein C , protein S and plasminogen level within normal limits .
Electrocardiogram :
sinus rhythm at 116 , axis of 23 , intervals of .14/ .07/ .42 , no ST-segment abnormalities .
Chest x-ray negative .
Head computerized tomography scan on 10/19 : 3 centimeter hyperdensity within the right putamenal area in the right external capsusle consistent with intra-parenchymal hematoma with mild local mass effect and surrounding edema .
No other areas of hemorrhage identified .
Head computerized tomography scan of 10/23 :
the area of hemorrhage the same , slightly more edema and mass effect .
Pulmonary angiogram :
no evidence of pulmonary emboli .
HOSPITAL COURSE :
Given the localization of the hematoma and the history of hypertension , the most likely cause for Mrs. Dua 's cerebellar hemorrhage is hypertension .
A magnetic resonance imaging study will be scheduled as an outpatient in three months to rule out a small vascular malformation if responsible for the hemorrhage .
At the time of discharge , Mrs. Dua has had a remarkable recovery .
She is now able to walk fitfully and use her left hand with no problem .
The exam is remarkable for a mild leftsided face , arm and leg weakness and sensory deficit that should further improve with physical therapy and occupational therapy help .
She will be followed by the OT / PT dept. for that .
Her hypertension was difficult to manage initially and required three days of Intensive Care Unit with A-line and Nipride intravenously .
It was finally under control with high doses of Captopril , Nifedipine , and hydrochlorothiazide .
The workup to rule out secondary cause of hypertension given the patient 's young age and the difficulty controlling the blood pressure was started as an inpatient and will be completed by Dr. ______________as an outpatient .
So far no secondary causes of hypertension were identified but causes like lymphocytic ? chromocytoma or renal artery stenosis have not been ruled out yet .
MEDICATIONS ON DISCHARGE :
hydrochlorothiazide 25 mg. po q.day , Captopril 75 mg. po three times a day , Nifedipine 40 mg. po three times a day .
CONDITION ON DISCHARGE :
Stable .
FOLLOWUP :
The patient will followup with Dr. ______________at Omend Hospital and with Dr. Deep at the Barb Memorial Hospital .
DISABILITY :
100% for now .
Will be reassessed after a month of intensive physical therapy and occupational therapy .
MATAANRE TAG , M.D.
TR :
ee / bihn
DD :
10/25/93
TD :
10/27/93
CC :