tokens: 245096078 FIH 9174858 12/February 997359 11/3/1992 12:00:00 AM Discharge Summary Unsigned DIS Report Status : Unsigned ADMISSION DATE : 11/3/92 DISCHARGE DATE : 12/6/92 HISTORY OF PRESENT ILLNESS : The patient is a 68 year old , right handed caucasian female , former R.N. who complained of several days of vertigo , one day of double vision , dysarthria and worsening of vertigo . She was seen at the outside hospital and put on aspirin for two days . An magnetic resonance imaging study showed basilar artery disease , questionable aneurysm . The patient was transferred to the Fairm of Ijordcompmac Hospital . An angiogram on 11/3 was consistent with thrombosis at the mid basilar artery . The patient was put on heparin and was stable since . PAST MEDICAL HISTORY : Hypertension for 20 years , high cholesterol , coronary artery disease with episodes of angina , no history of myocardial infarction , exercise treadmill or evaluation . She has had an inguinal hernia repair . A left breast lumpectomy was reportedly benign . ALLERGIES : The patient has no known drug allergies . MEDICATIONS ON ADMISSION : Mevicor 60 mg. PO q.d. , Cardizem 90 mg. w release PO q.d. , Questran one pack q.i.d. , Niacin 500 mg. PO b.i.d. SOCIAL HISTORY : She is a one pack per day smoker for the last forty years , denies alcohol , is a former nurse with the Storm Mor Hospital And Medical Center . PHYSICAL EXAMINATION : Her blood pressure was 190/90 when I first saw her on her second hospital day . She was afebrile , in sinus rhythm , pulse 60 . Neck supple . Lungs clear . Heart : regular rate and rhythm , without ectopy . A II / VI systolic ejection murmur is at the base , minimal radiation to the carotids . Abdomen : soft , without hepatosplenomegaly . Extremities : normal pulses , no clubbing , cyanosis or edema . The neurological examination : post angiogram her eyes were closed . She was very responsive , somewhat sleepy , she complained of chest pain , which was diffuse , non-localizing without electrocardiogram changes and persisted for several days and then went away completely . She was oriented to person , place , time and purpose , she recalled three out of three objects at five minutes , she is able to do calculations . She maintained her fixation on the conversation well . The cranial nerve exam : pupils reactive to light , extra ocular movements show good upgaze up to 3 mm. , good down gaze . Right lateral gaze , the right eye had 2 mm. of sclera showing , the left eye was normal , and there are a few beats of right beading nystagmus . The left lateral gaze , the left eye had 1 mm. of lateral sclera showing . Disks were flat . Sensory limb of the right eye corneal reflex is slowed , otherwise normal . Seventh nerve weakness on the right in a central pattern is present . Soft palate was in the midline and moved upward nicely , but did not respond to gag . Tongue protrudes 2 cm. with slight deviation to the right . Sensory exam was not remarkable , cerebellar exam was not possible . Motor exam showed greater than 4+ strength bilateral upper extremities and psoas unable to lift off bed . Quadraceps 2+ on the left and 3+ on the right . Gastroc. 3 on the left and 4+ on the right . Tibialis 3 on the left , 5+ on the right . Reflexes were diffuse 3+ , toes upgoing bilaterally . LABORATORY DATA : On admission , electrocardiogram showed less than 1 mm. of ST depression in V4 to V6 , which is likely the patient &apos;s baseline . CK &apos;s were mildly elevated but the MB fractions were not remarkable . A chest X-ray showed some left lower lobe atelectasis . Admitting creatinine was .7 , glucose 131 , white blood count was 10,000 , hematocrit was 40 , liver enzymes normal range . HOSPITAL COURSE : The patient was taken to the Intensive Care Unit after her angiogram . She was aggressively anticoagulated with heparin . A small intimal tear in the arch of the aorta during the angiogram , was without sequelae . She was doing well with at least 4+ strength in all of her extremities , when on 11/13 , she had an acute drop in her systolic blood pressure to 70 for unclear reasons and without evidence of acute sepsis . This was accompanied by substantial decrement in neurologic function . For a short time , she seemed &quot; locked in &quot; . She has made slow progress since then and at the time of discharge has 4-strength at the left elbow and 4+ in the left wrist and hand . Trace movement of the right elbow and 4-strength of the right wrist and hand . 4-to 4+ strength at the left ankle , 4+ strength at the right knee and right ankle . She is unable to lift either foot off the bed . The extra ocular movements are full . Tongue protrudes 4 cm . She is drowsy at times , but generally alert , responsive , interactive , able to talk in two to three word sentences when she wants to . She has severe memory deficits , but nevertheless , is able to engage in conversation , answers questions , names things well , does calculations and recognizes family members and states preferences . She has been working with Speech Therapy , occupational therapy and physical therapy closely and should continue to show improvement . She is anticoagulated on Coumadin and this has been stable . She is do not resuscitate in agreement with the wishes of her multiple family members . Follow up computerized tomography scans and magnetic resonance imaging studies have shown infarction in bilateral basis pontis , mid brain , the superior cerebellar areas , left thalamus , bilateral temporal lobes medially and inferiorly and left posterior communicating artery . The patient had fevers sporadically during this hospitalization with rising white blood counts . A chest X-ray documented a progressing left lower lobe infiltrate . Initially this improved on Clindamycin and Cefotetan , but fevers recurred on this antibiotic regimen . Sputum grew out Klebsiella pneumoniae , and she was treated with Gentamicin and Ancef for 14 days intravenous ( bug being sensitive to these two drugs ) . A left pleural effusion developed and this was tapped with ultrasound guidance , and found to be sterile , and without evidence of empyema . The patient is on Ciprofloxacin . The day of discharge is day #3 of 7 , after which antibiotics should be totally discontinued . She has developed bad thrush in this setting , she is not yet able to swallow and so she is on Nystatin swish and spit five times a day . She also gets Peridex to clean out her mouth . Once her liver enzymes are completely normal , a seven day course of Fluconazol may be helpful if the thrush is not spontaneously resolving off of antibiotics . She has been afebrile for greater than 10 days , including several days on oral antibiotics . The patient &apos;s liver enzymes were noted to be elevated mid way through her hospital course , to about three times normal , especially the SGOT and SGPT . These have spontaneously reversed , and are nearly normal at the time of discharge . A right upper quadrant ultrasound documented gallstones , without evidence of common bile duct dilatation or active cholecystitis . The exact cause of her liver enzyme elevation is unclear , but we are being careful about administering drugs , which might irritate the liver . The patient had a steady decline in her hematocrit during this hospitalization . Iron studies are all entirely normal , her anemia is attributed to anemia or chronic disease with hypoproliferation as well as multiple phlebotomies . The plan is to give her folic acid , but not iron . The patient &apos;s potassiums have been repeatedly low and require daily checks and repletion . This is thought due to the extensive course of Gentamicin which she received . This must be carefully checked despite the standing order for potassium . The patient has had low sodiums during this hospitalization . This may due to her central nervous system process or her pulmonary process , with fluids administered as described , she should not have any problems from this . Her sodiums were never below 130 . She does well with tube feeds . Her tube feeds orders are as follow : full strength Replete with fiber at 70 cc. per hour . In addition , the patient gets 250 cc. of juice ( not water ) three times a day . She also gets Lactinex granules three packages in each bottle of tube feeds . She also gets Metamucil one teaspoon with the first bolus of juice each day . Please note that evaluation by the swallowing therapist , showed that the patient is aspirating at this time , but there is great hope from the nature of her deficit and the good movements of her tongue that normal swallowing should return soon . It is for this reason that she is discharged with an nasogastric tube and that no plans for G tube placement are made at this time . She has a history of of angina without myocardial infarction that has not been worked up . She did have brief chest pain twice during this admission that did not correlate with electrocardiogram changes . In the first week of November , her electrocardiogram showed T wave inversions in the lateral leads , correlating with an increase in the LDH , but not CK . This did not normalize with administration of Isordil and the patient denied chest pain at this time . As of 4/7 , her electrocardiogram had reverted back to normal and there is no evidence of congestive heart failure or continued electrocardiogram changes , and chest pain is absent . Her cholesterol was 350 here . She has been off of her hypercholesterol medicines . These can be restarted when it is deemed reasonable , in view of her acute disease and recently elevated liver enzymes . Note that the liver enzymes were normal on admission , at which time she was taking all of the above cholesterol medicines . MEDICATIONS ON DISCHARGE : Metamucil 1 teaspoon q.d. , with first bolus of juice , juice 250 cc. down nasogastric tube t.i.d. , tube feeds as above , Lactinex as above , Tagamet 800 mg. nasogastric tube qhs , Nystatin swish and spit 10 cc. five times a day , Cardizem slow release 90 mg. PO q.d. , Folic Acid 1 mg. PO q.d. , Ciprofloxacin 500 mg. PO b.i.d. , discontinue on 12/10/92 KayCiel 30 mEq. down nasogastric tube q.d. , Peridex 10 cc. swish and spit q.i.d. , Coumadin 4 mg. nasogastric tube on odd days , alternating with 5 mg. nasogastric tube on even days , once daily , Tylenol 650 mg. PO and PR q6hours PRN pain , Nystatin powder to axilla and groin as needed . DISCHARGE DIAGNOSIS : Basilar artery stenosis with basilar thrombosis and &quot; top of the basilar &quot; syndrome . Includes recent infarct to pons , mid brain , left thalamus , bilateral temporal lobes and left visual cortex , on Coumadin . The patient is do not resuscitate at family &apos;s request . Left lower lobe pneumonia , resolving now on oral antibiotics . Gallstones , thought to be inactive . Improving liver enzyme elevation . Anemia , discharge hematocrit 28 , not iron deficient . Low potassium , thought due to Gentamicin . Low sodium , responsive to fluid restriction . History of coronary artery disease . Thrush . High cholesterol . The patient needs prothrombin time checked daily , patient needs potassium checked daily , patient needs sodium checked at least every other day . DO JOASSCCHIRD , M.D. DICTATING FOR : NAREA SWALLOW , M.D. TR : sw / bmot DD : 12/6/92 TD : 12/06/92 CC : Dr. Namarce May STAT