tokens: 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 &apos;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 &apos;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 :