DATE OF ADMISSION: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who came in to the hospital when she was found initially unresponsive at 4 o’clock in the morning, at her home, on the floor. The patient lives with her grandson. The previous night, she was active, alert and oriented x3, talkative, walking. They were anticipating taking a trip this morning. The family members were gathering to go on vacation and the patient was found at 4 o’clock in the morning at her house, on the floor. The patient was unresponsive. There was no known seizure activity. No admission of any chest pain prior. It is unknown how long the patient was down, but likely she had gotten up and was anticipating getting ready when she may have fallen and became unresponsive. There was positive urine incontinence. The patient was also found to be a little gagging. She was also aphasic. At that time, EMS was called and the patient was brought in for further evaluation and workup. Here, it was found that the patient had an acute CVA with intracranial bleed. There was particularly large intraparenchymal, predominantly intrathalamic hemorrhage in the left thalamus with some midline shift towards the right by approximately 3 to 4 mm, per CAT scan. The blood had entered the ventricular system and there was surrounding white matter edema. There was also evidence of underlying periventricular chronic-type ischemic disease and also mild left ethmoid sinus disease. However, her bony windows were grossly intact. At that time, the patient was admitted to the intensive care unit and she has been seen by Dr. Doe, who is the neurosurgeon, and at present, she does not appear to be in any pain, is somewhat responsive to our commands, very lethargic, able to move her left side; however, minimally moves her right. She is also responsive to noxious stimuli. The patient can open her eyes; however, she is not talkative at present.
PAST MEDICAL HISTORY: Mainly obtained through the family members and the chart. However, the patient has a history of essential tremor and also high blood pressure.
PAST SURGICAL HISTORY: Not available.
MEDICATIONS: Not available at present.
ALLERGIES: None known.
SOCIAL HISTORY: The patient had normal activities of daily living just prior to this acute incident. She lives with her grandson. She was talkative and walking.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure initially when she came in was 172/102, heart rate 64, respiratory rate 18, appeared to be in normal sinus rhythm, O2 saturation 97% on room air.
GENERAL APPEARANCE: The patient looks frail, lying in bed, responsive and does obey commands such as opening her eyes and squeezing her fingers to command and also can move her left lower extremity. Otherwise, does not appear to be in any pain. Appears to be in no apparent distress at this time.
NEUROLOGICAL: Cranial nerve exam was not able to be elicited given the patient’s unresponsive and very lethargic state. However, pupils appear very sluggish to reaction; otherwise, are equal and round. The patient has upper extremity and lower extremity strength of about 2+ in her upper and lower extremity bilaterally, and her right side is 0 to 1/5. Babinski is downgoing on both sides bilaterally. The patient is responsive to noxious stimuli. Reflexes were also elicited and 2+ in upper and lower extremities bilaterally. Otherwise there appears to be no fasciculations, no fibrillation. There is no posturing.
CARDIOVASCULAR: Appears to be regular rate and rhythm. S1, S2. No S3 or S4. No murmurs.
LUNGS: Clear to auscultation bilaterally with no rales, rhonchi or wheezes.
ABDOMEN: Benign with no rigidity, rebound tenderness or guarding.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: Sodium 138, potassium 3.9, chloride 104, bicarb 28, BUN 22, creatinine 0.9, glucose 115. Liver function tests were normal. Bilirubin was 1. Troponin enzymes x1 negative. PT/INR and PTT were normal. CBC revealed a white blood cell count of 14.4, hemoglobin of 16.2, hematocrit of 48.4, platelet count 164,000. Neutrophils were 84.9, lymphocytes were 9.3, monocytes were 4.9 and eosinophils were 0.8.
CT scan of the head and brain was as reported in the initial history of present illness. Chest x-ray was also done, portable, single frontal view. There was no active pulmonary disease. EKG was also done, which appeared to be in sinus rhythm, ventricular rate of 69 with premature atrial complexes and PVCs. Otherwise, there were no Q waves, ST elevations or T-wave inversions.
ASSESSMENT AND PLAN:
1. Intracranial bleed with acute cerebrovascular accident. We would recommend admitting the patient to intensive care unit for further progression of acute CVA. We will recommend neurosurgery evaluation for possible drainage of bleed. Recommend neurological evaluation to optimize medical management with control of blood pressure, lifestyle modifications and any risk factors for CVA. We will proceed with stroke protocol per ICU. Follow up with MRI brain, 2-D echo, carotid ultrasound, lipid panel and further lab evaluation. At present, there appears to be a large left intrathalamic hemorrhage with extension to the ventricular system with a midline shift. We will follow for further progression and evaluation of neurological deficits and deficits compromise.
2. Hypertension. We will aggressively control blood pressure to further minimize her risk of further ischemic infarct. Follow up serial lipid panels and optimize medical management.
3. Disposition. We will discuss case with family members. Power of attorney at present is a son, whom I have discussed the case with in depth. We will follow up her acute CVA while she is in the intensive care unit and further monitor hospital course. Likely, the patient will need extensive physical medicine and rehabilitation to return to activities of daily living. Prognosis at present is critical.
