tokens: Admission Date : 2009-12-28 Discharge Date : 2009-12-31 Date of Birth : 1964-03-23 Sex : F Service : NEUROMEDIC HISTORY OF PRESENT ILLNESS : Mrs. Wisniewski is a 45-year-old woman with multiple familial cavernous hemangiomas . She is right-handed . She was in her usual state of health until one and a half weeks prior to admission . She developed an ear ache , for which she saw her primary care physician , Evelyn was prescribed cortisone drops . A few days later she complained of dizziness . This was mostly described as feeling unsteady on her feet . She stated that she had trouble knowing if her feet were touching the ground . She was seen again by primary care physician , Roderick since she had complaints of dizziness , as well as a new complaint of decreased hearing and the sensation of static in her ears , meniere 's disease was considered . She was given an oral prednisone taper . This unsteady gait progressed , and then she subsequently started to develop a pins and needle feeling in the face , hands and feet bilaterally . Her hearing got progressively worse and the sound of static increased . She was very fatigued . At an outside hospital , head CT revealed a 1.5 cm diameter hyperdense mass in the pons , slightly off center to the right . She was transferred here for further care . PAST MEDICAL HISTORY : Notable for multiple cavernous hemangiomas . She has had at least two bleeding episodes in the past , mostly described as being accompanied by generalized weakness . She has had at least two generalized seizures in the past , but she has not had one since she was 26 years old . She was never on an anticonvulsant due to her former beliefs as N. Derk Scientist . She no longer observes that belief system . MEDICATIONS : Prednisone taper as above . ALLERGIES : None . FAMILY HISTORY : Strong maternal history of hemangiomas . PHYSICAL EXAMINATION : Temperature 99.2 . Pulse 60 . Blood pressure 120/80 . Respiratory rate 14 . In general , she was a thin well-appearing woman in no acute distress . Sclera were anicteric . Neck was supple . Chest was clear . Cardiovascular exam revealed a regular rate and rhythm with no murmurs , rubs or gallops . Abdomen soft , nontender and distended . Extremities showed no edema . Neurologically , she was awoken from sleep by voice , cooperative , but mildly drowsy . She became more alert during the remainder of the exam . Speech was fluent but slow , and there was long response latencies before she would initiate speech . She otherwise had normal spontaneous movements and facial expression and did not appear to be abulic . She had normal comprehension . She was able to give a detailed history in an organized manner . There was no dysarthria . Language was normal . There was no evidence of any special neglect . Pupils equal , round and reactive to light . Visual fields were full . Extraocular movements were full with normal smooth pursuit to the left . Pursuit was interrupted by >.....< when tracking from left to right . She had sustained gaze holding nystagmus in both horizontal directions . There was no rotary component . She had a mildly widened right palpable fissure . There was decreased excursion of the right mouth and flattening of the right nasolabial fold ( mild ) . Light touch was subjectively abnormal on both sides of the face . Hearing was diminished for conversational speech . Palate and tongue moved normally in the midline . There was a mild left pronator drift . Finger tapping and rapid alternating movements were slow on the left and she had trouble isolating individual finger movements . There was mild finger-to-nose dysmetria on the left . Power was mildly diminished in the finger extensors and hand intrinsics on the left , otherwise , power was full throughout . Reflexes were brisk in the legs with 4-5 beats of clonus at the ankles bilaterally . She had bilateral upgoing toes . She made mistakes with position sense , roughly at chance level with both great toes and the left first finger , position sense in the right limb seems preserved . Gait was wide based , very unsteady , veering to the left and to the right . She retropulsed and would have pitched backwards without the assistance of the examiner . LABORATORIES : White blood cell count 7.8 with 86% polymorphonuclear cells , 11.1 lymphocytes , hemoglobin 14.3 , hematocrit 40.5 , MCV 88 , INR 1.0 , PTT 24.7 , PT 12.3 , platelet count 295,000 , glucose 81 , BUN 15 , creatinine 0.8 , sodium 142 , potassium 4.2 , chloride 104 , CO2 26 , calcium 9.3 , phosphate 4.8 , magnesium 2.3 . MRI of the brain revealed multiple foci susceptibility artifact within the brain . These were seen best in gradient echocardiogram images . There was a large focus of subacute blood products in the mid to low pons suggesting recent hemorrhage into a cavernous angioma . There was some mild surrounding edema . There are also tiny foci artifact within the cerebellum and base of the pons . There was a larger area of susceptibility artifact in the left temporal lobe , right frontal lobe , and the splenius of the corpus collasum . The brain parenchyma was otherwise normal . There was mild enhancement of the pontine hemorrhagic mass but none elsewhere . There was no areas of restricted diffusion to indicate infarction . MRA of the brain was unremarkable . There was no communication >.......< in the visualized vessels and the angiomas . Follow-up CT was obtained the second day of admission . There was no evidence of developing hydrocephalus , which was a concern due to the surrounding edema , and possible suppression of the fourth ventricle . There was no significant change in size of the subacute pontine hemorrhage . HOSPITAL COURSE : Mrs. Wisniewski is a 45 - year-old woman with a strong family history of cavernous angiomas . She has had several prior bleeding events and presented with a subacute bleed in the mid to lower pons . There was relatively central in location , with only a slight right-sided predominance . Her physical examination remained relatively unchanged , with resolution of the subtle left hand weakness and right facial weakness . Her gait remained severely ataxic , likely secondary to sensory deafferentation , as well as involvement of crossing pontine cerebellar fibers . Therefore , it was recommended that she have aggressive Physical Therapy at an Acute Rehabilitation Center . The case was discussed with Dr. Harold from the Falmouth Hospital . He has followed this family in the past and will see her in follow-up . We will arrange to have a copy of the MRI scans sent to him . DISCHARGE DIAGNOSES : 1. Familial cavernous hemangiomas , status post a subacute pontine hemorrhage . 2. Severe gait ataxia . DISCHARGE MEDICATIONS : 1. Gabapentin 100 mg po t.i.d. for paresthesias . 2. Colace 100 mg po b.i.d. 3. Zantac 150 mg po b.i.d. 4. Prednisone taper completed . Andre R. RATAN , M.D. 23-397 Dictated By : Maria A Singler , M.D. MEDQUIST36 D : 2009-12-31 14:05 T : 2009-12-31 14:57 JOB #: 71678 Signed electronically by : DR. Juan R. RATAN on : TUE 2010-03-02 8:13 PM ( End of Report )