tokens: 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