tokens: Admission Date : 2011-03-10 Discharge Date : 2011-03-15 Date of Birth : 1927-10-26 Sex : F Service : Medford HISTORY OF PRESENT ILLNESS : This is an 83 year old woman with a history of hypertension who presents with slurred speech when dehydrated . She has paraplegia secondary to HTLV exposure while on vacation in the Bahamas six years ago . She presented with three days of general malaise , nausea , vomiting , shortness of breath , cough productive of white sputum . She awoke with nausea on the day of admission and pleuritic chest pain . She reports no sick contacts. The patient has some difficulty talking and grasping right hand . She came to the Emergency Department on the 2011-03-10 , with temperature of 99.0 F .; blood pressure of 97/50 ; heart rate 100 ; respirations 27 ; O2 saturation 84% on room air and 94% on two liters . The patient had coarse rhonchi on examination . Chest x-ray revealed mild pulmonary edema . Chest CT scan was negative for pulmonary embolism but positive for consolidation . She was started on Levofloxacin but the patient became hypotensive at that point with blood pressure of 70/45 and received a normal saline bolus to boost her blood pressure to 99/60 ; however the patient was admitted to the Medical Intensive Care Unit for overnight observation because of her somnolence and hypotension . She was transferred to the Everett Firm on the 2011-03-11 and was mentating well and was stable for transfer . PAST MEDICAL HISTORY : 1. Positive lupus anti-coagulant . 2. Basilar stenosis . 3. Prior transient ischemic attacks . 4. Right medial malleolus repair in 2004-08-05 . 5. Paraplegia secondary to HTLV from a trip to the Bahamas five to six years ago . 6. Hypertension . 7. Chronic diarrhea with multiple admissions for dehydration with most recent one on 2011-02-26 . 8. Venous stasis . 9. Depression . 10. Seizure history on Neurontin . 11. Left CMED cataract surgery in 2009-10-05 . 12. Chronic muscle spasms . ALLERGIES : Penicillin for which she reports a rash and dyspepsia when taking uncoated aspirin . She has a questionable sensitivity to iodine . MEDICATIONS AS OUTPATIENT : 1. Enteric-coated aspirin . 2. Aggrenox . 3. Zanaflex . 4. Neurontin 300 mg three times a day . 5. Celexa 10 mg daily . PHYSICAL EXAMINATION : On admission examination she was a well developed , well nourished female in no apparent distress . She was alert and oriented times three . Speech was fluent . Her lungs revealed coarse bilateral rhonchi from base to midline . Cardiovascular examination is notable for a regular rate and rhythm ; no murmurs , rubs or gallops . Abdomen is soft and obese , nontender . Normal bowel sounds present . Extremities notable for two plus lower extremity edema and the ankles were noted to be in pressure stockings . LABORATORY : White blood cell count were 11.8 , hematocrit 31.5 , platelets 151 . Chem-7 was a sodium of 140 , potassium of 3.0 , chloride 108 , bicarbonate 24 , BUN 22 , creatinine 1.0 and glucose 117 . The patient also had a head CT scan in the Emergency Department before coming to the Unit which reported no recent bleed and no change from a prior CT scan done on 2011-03-04 . EKG is notable for sinus tachycardia at 100 beats per minute , normal axis . ..... done on 02-24 , notable for mid-basilar artery high-grade stenosis . HOSPITAL COURSE : After transfer to the Floor , the patient was continued on Levofloxacin for a ten to 14 day course for presumptive pneumonia . Due to her chronic diarrhea she was repleted with intravenous fluids . For her depression , continued on Citalopram 10 mg daily . For her paraplegia and associated muscle spasticity she was continued on her Zanaflex . For deep vein thrombosis prophylaxis she was treated with subcutaneous heparin and for gastrointestinal prophylaxis she was treated with Protonix . She was also evaluated by Physical Therapy and Speech and Swallow because of some report of dysphagia . Physical Therapy felt that the patient was cleared for transfer home with services . Occupational Therapy was also in agreement with the patient 's disposition home with services . The patient was able to advance her diet well from liquids to solids , however , she was plagued with a persistent cough and some low grade fevers to 99.0 F . Speech and Swallow evaluated the patient at bedside and recommended advancing to regular diet with regular consistency and saw no evidence of any dysphagia . There was some question regarding restarting of the patient 's Coumadin given her positive lupus anti-coagulant status as well as the presence of her basilar artery stenosis . The patient was discharged on the 2011-03-15 on the following medications . DISCHARGE MEDICATIONS : 1. Levofloxacin 250 mg q. day for ten days . 2. Aspirin / dipyridamole 25/200 mg capsules taken two times a day . 3. Neurontin 300 mg taken three times a day . 4. Subcutaneous heparin taken 5000 units twice a day . 5. Albuterol multiple dose inhalers , one to two puffs q. six hours as needed . 6. Atrovent multiple dose inhalers , one to two puffs q. six hours as needed . 7. Citalopram 10 mg q. day . 8. Lisinopril 2.5 mg once a day . 9. Trazodone 25 mg q. h.s. p.r.n. 10. Protonix 40 mg q. day . 11. Zanaflex 2 mg twice a day . 12. Tylenol 325 mg , one to two tablets q. four to six hours p.r.n. 13. The patient was also discharged with the restarting of warfarin 2 mg daily . DISCHARGE INSTRUCTIONS : 1. She was instructed to have blood drawn by the Visiting Nurses Association the day after discharge and then a few days after discharge the same week to have INR . Will also have INR checked at once weekly until target of INR of 2.0 to 3.0 is reached . 2. The patient was instructed to contact Dr. Ralph at ( 428 ) 678-6930 , who is covering for her primary care physician , Dr. Erika Witt , to adjust her dosages based on the INR levels . 3. The patient also had a Gastrointestinal Clinic follow-up on 2011-03-28 . She is to follow-up with Dr. Geraldo Davis . 4. She was also instructed to follow-up with Dr. Reid from Neurology within a month at ( 382 ) 716 4151 , given her neurological deficits during this presentation . Brenda L. Nelson , M.D. Dictated By : Rodolfo X Gifford , M.D. MEDQUIST36 D : 2011-04-18 16:17 T : 2011-04-18 22:11 JOB #: 46153 Signed electronically by : DR. Dorothy Donahue on : TUE 2011-04-19 3:15 PM ( End of Report )