tokens: 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 &apos;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