412141256
FIH
3833231
39626/6vf7
817292
10/3/1994 12:00:00 AM
Discharge Summary
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
10-03-94
DISCHARGE DATE :
10-06-94
HISTORY OF PRESENT ILLNESS :
This 85 year old man was admitted because of the new onset of focal left-sided seizure and unresponsiveness .
He had a past history of ischemic cardiomyopathy with an ejection fraction of 10 , mild aortic stenosis and a right middle cerebral artery territory stroke in 07/94 .
He was at Orlak on the day of admission and was found unresponsive with left tonic-clonic movements , greater in the arms than in the legs .
He was transferred to Fairm of Ijordcompmac Hospital , where seizures were stopped with 2 mg of Ativan .
He was loaded with IV Dilantin .
He remained unresponsive with poor airway protection .
PHYSICAL EXAMINATION :
Eyes were deviated to the left .
He was flaccid bilaterally .
He had no oculocephalic reflexes .
After one hour his eyes were midline and he remained unresponsive .
HOSPITAL COURSE :
By the patient and his family 's prior wishes , the patient was extubated .
An electroencephalogram revealed generalized slowing without ictal events .
He had no carotid bruits .
He had stertorous breathing , positional tremors of the left upper extremity , a spastic left hemiparesis in flexion .
He withdrew both legs to painful stimuli .
The right upper extremity was flaccid and paresthetic .
Again , comfort measures only were undertaken as per the patient 's previous wishes and the family 's current insistence .
At 1:15 PM on 10/06/94 , the patient was found unresponsive with no heart sounds , carotid pulse , respiratory excursions , or pupillary reactions .
His family was notified .
Consent for autopsy was denied .
DISCHARGE DIAGNOSIS :
1. Left middle cerebral artery territory cerebral infarction .
2. Cardiomyopathy .
3. Residual of previous right middle cerebral artery stroke .
RE RHALTFETHFONGPOCE , M.D.
TR :
cnm / bmot
DD :
10-18-94
TD :
10/19/94
CC :