523704694
PRGH
67119280
480282
10/23/1999 12:00:00 AM
Discharge Summary
Signed
DIS
Admission Date :
10/23/1999
Report Status :
Signed
Discharge Date :
11/02/1999
PRINCIPAL DIAGNOSIS :
Left sided spastic hemiparesis , status post surgical correction of C-1 , C-2 dural AVM .
HISTORY OF PRESENT ILLNESS :
Ms. Breunlinke is a 69 year-old right handed woman , status post surgical correction of a C-1 to C-2 dural AVM in January , 1998 , now presenting with a one month history of increasing left sided weakness and pain with spasticity , occasional difficulty swallowing and abdominal pain .
She was originally admitted to the Verg Medical Center in January , 1998 , because of a one year history of left sided weakness and spasticity .
She was found to have intermedullary lesion at C1-2 level which on biopsy showed abnormal vasculature , hemosiderin deposit , leading in turn to the discovery of a dural arteriovenous malformation at that level which was surgically corrected .
The postoperative period was complicated by transient swallowing difficulty , increasing left sided weakness and urinary retention .
She was discharged to inpatient rehabilitation where she made significant progress toward recovery .
As of the beginning of September , 1999 , she was able to swallow without difficulty , urinate without difficulty ( although bowel movements have been problematic ) .
Functionally , she was at the level of pre-gait training and able to stand and take several steps with upper body support .
Over the past 4-5 weeks her functional level has progressively deteriorated .
She is now unable to stand and needs assistance to sit up .
Her left arm has developed a flexure contraction and she reports intermitttent pain in the left arm and leg which occurs both spontaneously and is also triggered by contact .
She has developed some new swallowing difficulty and since her transfer to a long term inpatient care facility , she has lost ten pounds .
She denies dysuria or excessive urinary frequency .
Over the past several weeks she has also developed severe intermittent abdominal pain , localized to the suprapubic area , left greater than right , occurring intermittently .
The patient feels this is secondary to her hemorrhoids , although it does not clearly localize to the rectum .
This pain often follows bowel movement but does occur spontaneously .
PAST MEDICAL HISTORY :
Significant for Insulin dependent diabetes mellitus , atrial fibrillation , hypothyroidism , hypertension , depression , frequent urinary tract infections , neuropathic pain syndrome and osteoporosis .
MEDICATION :
On admission include Cozaar 75 mg q.d. , Coumadin 2 mg/1 mg alternate days , Synthroid 175 mcg q.d. , Zoloft 50 mg q.d. , Zantac 150 mg b.i.d. , Diabeta 25 mg q.d. , Proctofoam 1% q.i.d. , Demerol 100 mg q 6 p.r.n. , OsCal 2 tabs t.i.d. , multivitamins and KCl supplements , Dulcolax 5 mg q.d. , Senokot 2 tabs q h.s. , Metamucil 1 tablespoon b.i.d. , Detrol 2 mg b.i.d. , Neurontin 200 mg t.i.d. , HydroDIURIL 12.5 mg q.d. , Valium 10 mg q 8 p.r.n. muscle spasm , Insulin by sliding scale and levofloxacin 500 mg q.d. beginning October 23 , 1999 .
ALLERGIES :
The patient is allergic to Hydralazine , codeine , ace inhibitors , Nifedipine and Percocet .
PHYSICAL EXAMINATION :
On admission , heart is regular rate and rhythm without murmur .
Lungs are clear to auscultation bilaterally .
Abdomen is soft , with marked suprapubic tenderness and reduced bowel sounds .
Anal tone is reduced .
Rectal examination is nontender and stool is guaiac negative .
Neurologically , the patient is alert and oriented times three with normal speech , language and repetition .
Cranial nerves :
pupils are 4-6 mm bilaterally , extraocular movements were full without nystagmus .
Eye closure and smile are symmetric .
Tongue is midline .
Facial sensation is sensation .
Strength :
The tone is markedly increased in bot legs with left greater than right .
Left arm shows a flexor contracture and markedly increased tone .
The right arm shows moderate increased tone .
Power :
The left upper extremity shows reduction in motor power ranging from 2/5 in the triceps , 4/5 in the biceps , and 3-4/5 in the wrists and hand intrinsics .
The right upper extremity shows generalized reduction in strength , 4/5 in all joints .
In the lower extremities on the left hip flexor is 1/5 , knee flexion and extension is 3/5 and 4/5 respectively and plantar and dorsiflexion is 4/5 .
The right lower extremity shows a 3/5 on hip flexion , 4/5 at knee flexion and extension and full power on dorsi and plantar flexion .
Reflexes :
Upper extremities are very brisk bilaterally and symmetrical 3+. There is positive tremor reflex on the left and absent on the right .
Lower extremities show patellar reflexes 3+ left , 4+ right , no cross deductor reflexes and absent ankle jerks .
There is no clonus on the right but sustained clonus ( 10-12 beats ) on the left .
Plantar responses :
toes are upgoing on the left , down going on the right .
Sensory :
The patient has diminished vibration and propioception in the left upper and lower extremity and decreased temperature , light touch and pinprick sensation in the right upper and lower extremity consistent with a high cervical spinal sensory level .
Cerebellar ; The patient demonstrates an intention tremor on finger to nose with the left hand .
Fine motor movements are slow but accurate in the left and right hands .
LABORATORY DATA :
Sodium 140 , potassium 3.8 , chloride 100 , bicarbonate of 30 , BUN of 13 , creatinine 0.8 , serum glucose 228 .
White blood count is 7,000 .
Hematocrit is 37.6 , platelet count is 148,000 .
Prothrombin time is 15.9 with an INR of 1.7 .
PTT is 24 .
Urinalysis from October 21 , is positive for Citrobacter susceptible to ciprofloxacin , gentamycin , nitrofurantoin , tetracycline and Bactrim .
Electrocardiogram shows no P-waves .
The patient is fully paced .
HOSPITAL COURSE :
On admission , a CT scan of the head with and without contrast was performed , showing a missing posterior arch at C-1 and metallic clips at the craniocervical junction consistent with prior surgical intervention .
No arteriovenous malformations are identified ; there is no evidence of recurrence of her former vascular malformation .
No intraspinal lesions are identified .
Upon further review of Dr. Laymie Fields , Department of Neuroradiology , review of the cervical spine on CT reveals no extrinsic compressive lesions impacting the spinal cord and no enhancing lesions of the spinal cord with contrast .
Angiography performed on October 31 , 1999 , showed normal vascular distribution of the head and neck with no recurrence of arteriovenous malformation .
During this admission , the patient was started on Baclofen 10 mg p.o. t.i.d. for spasticity .
Coumadin was discontinued .
The patient was given aspirin 325 mg p.o. q.d.
The patient was also given Valium 5-10 mg p.o. t.i.d. for muscle spasm .
She was continued on Demerol 50 mg q 6-8 hours p.r.n. for left arm and leg pain .
Upon further review of CT and angiography results with Neuroradiology and Neurology service , it was decided that CT myelography was not indicated at this time .
Note , the patient is not a candidate for magnetic resonance imaging secondary to ferromagnetic intracardiac pacing device .
DISPOSITION :
The patient was discharged back to Raka St , Mcape Garl , long term facility .
We recommend daily physical therapy and occupational therapy to maximize functional capacity with optimization of pharmacological regimen for spasticity including Baclofen , Valium and adequate analgesia .
The patient is to followup in Neurology clinic , Verg Medical Center with Dr. Deida K. Areke and / or Dr. Istranmuna Cord in 4-6 weeks time .
Dictated By :
DEIDA K. LONG , M.D.
Attending :
ISTRANMUNA B. CORD , M.D. VR52 PH501/3560
Batch :
1445
Index No. MUZHFDOZK0
D :
11/02/99
T :
11/02/99 KE9