DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who was transferred to the hospital from home after she was noted to have multiple falls, weakness of the legs, and dizziness. However, there was no loss of consciousness or syncope.
HOSPITAL COURSE: The patient was admitted to rule out CVA and also to rule out an arrhythmia and hypoglycemic episodes. Blood sugars were stable all through the admission. The patient was admitted to telemetry monitoring and EKG monitoring, and EKG showed variable heart rate. EKG showed sinus bradycardia with first-degree heart block and left anterior fascicular block. A CAT scan was done, which showed a right internal capsule and cardiac infarct, no bleeding. No change in midline shift.
The patient was admitted to telemetry monitoring. Blood pressure medications and diabetic medications were continued. Blood pressure appears to be stable as do blood sugars. The patient was also continued on other cardiac medications. She has hypercholesterolemia and Zocor is to be continued. The patient was also continued on Pletal for her peripheral vascular disease. Aspirin and Plavix were started. The patient was started on therapy. A carotid study was done, which showed minimal stenosis of the right internal carotid artery and 60% stenosis, left internal carotid artery.
Vascular surgery evaluation and consult was obtained, whose opinion is that in view of the 60% carotid stenosis, no intervention at this time and to continue aspirin and Plavix, and to get an ultrasound of carotid in another six months’ time. The patient also had an echocardiogram, which showed good LV function, left ventricular hypertrophy, aortic stenosis, small MR, moderate AR. However, the patient has a good blood pressure and appears stable. The patient needs physical therapy in view of deconditioning and CVA and gait training. The patient is to be discharged to rehab today and is to continue on her medications.
DISCHARGE DIAGNOSES:
1. Cerebrovascular accident, right internal capsule and cardiac infarct.
2. Dizziness, resolved.
3. Left carotid stenosis, 60%.
4. Hypertension.
5. Aortic stenosis.
6. Diabetes mellitus.
7. Hypercholesterolemia.
8. Osteoporosis.
9. Peripheral vascular disease.
