DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Intracranial hemorrhage secondary to coagulopathy, hypertension, crack cocaine use.
2. Methicillin-sensitive Staphylococcus aureus bacteremia.
3. Abscess of the left antecubital fossa.
4. Paralytic ileus.
5. Gastrointestinal bleed.
6. Right hemiparesis secondary to intracranial hemorrhage.
7. Cutaneous candidiasis.
BRIEF HISTORY AND HOSPITAL COURSE: The patient is a (XX)-year-old gentleman with a history of diabetes, hypertension, and cutaneous candidiasis who was recently diagnosed with deep venous thrombosis, being treated with Coumadin, who presented to the emergency department with weakness on the patient’s right side and headache. The patient was brought by paramedics to the emergency department. The patient was examined and found to have flaccid paralysis on the right with some residual handgrip noted by the ER attending, upgoing Babinski on the right.
The patient underwent a stat CAT scan of the head to rule out intracranial bleed. At that time, the patient’s blood pressure was 178/98. The patient’s initial laboratory workup included hemoglobin of 12.4, hematocrit 37.6, white cell count 8400, and platelet count 416,000. Troponins initially were negative. INR was 3.3, PTT of 56 and PT of 32. The patient’s electrolytes were balanced. CAT scan of the head revealed acute left parietal hemorrhage. No shift in midline structures with unusual blood-fluid level seen suggesting an underlying cystic structure or mass. Diagnostic possibilities per Radiology consist of an AV malformation or hemorrhagic tumor.
The patient was started on labetalol drip to control the patient’s blood pressure. He was given 10 mg of vitamin K along with 2 units of fresh frozen plasma to correct the coagulopathy. Coumadin was discontinued obviously. The patient was started on Dilantin 100 mg IV q. 6h., morphine for pain, and admitted to the ICU for cardiac monitoring and close observation. Current diagnosis on admission to the ICU is hemorrhagic stroke. The patient was begun on Lopressor 2.5 mg q. 6h. Transfusion and vitamin K were running. Echocardiogram 2D was ordered following laboratory for coagulation status. Serial cardiac enzymes and insulin sliding scale, given the patient’s diabetes mellitus, and urine toxicology was ordered.
Neurosurgery was consulted. Neurology was consulted. The history was brought to the surface that the patient had a history of smoking crack cocaine one hour prior to admission. The patient was seen by Neurology, who agreed with the current plan and ordered a followup CAT scan/MRI for the a.m. to note any further extension of the intracranial hemorrhage. While in the ICU, the patient continued to have labile blood pressures with increase in irritability and had some gastroparesis. Nasogastric tube was placed and 1200 mL of fluid and coffee-ground emesis were noted.
Gastroenterology was consulted with the diagnoses of possible peptic ulcer disease, cirrhosis, esophagitis-gastritis, also some Mallory-Weiss tear. He noted no active bleeding at this current time. His suggestion was to add Protonix b.i.d. and follow up serial CBCs in patient for possible endoscopy if bleeding noted. Infectious disease was later consulted secondary to fever of 101.2 with positive blood cultures growing gram-positive cocci in clusters, later seen as methicillin-sensitive Staphylococcus aureus. The patient also had an infected or superficial thrombophlebitis of the left antecubital area on a prior IV site. Infectious disease began treating the patient with vancomycin, rifampin, and gentamicin. The patient underwent a transesophageal echocardiogram, which was noted to be negative for vegetations or thrombi.
The patient’s urine toxicology returned with positive cocaine, positive opiates, and positive benzodiazepine confirming the past history. There was some question of whether the patient had some cocaine withdrawal given the labile blood pressures, irritability, and gastroparesis. The patient underwent a followup to the initial CAT scan with a MRI noting an acute hematoma of the left parietal lobe, abnormal vessels were demonstrated essentially within the hematoma, and postcontrast sequences raises the question of underlying AV versus hemorrhagic neoplasm. MR angiogram confirmed these results.
The patient later had a three-vessel cerebral angiogram, noted no AV malformation present. The patient also had a second MRI of the head to see if there is any progression or evolution of the intracranial bleed, of which there was not any progression. The patient was later evaluated and taken to the OR by Vascular Surgery secondary to an abscess in the left antecubital area, which was incised and drained. Pharmacologically, for blood pressure management, the patient was later switched from labetalol IV to Catapres patch TTS-2 weekly, Nicoderm patch, and begun on Lopressor and diltiazem.
While in the intensive care unit, the patient also had physical therapy and OT consult and treatment along with speech therapy. A summary of the ICU care included serial radiographic studies of the head noting a stable intracranial bleed, infectious disease secondary to temperature with appropriate antibiotic coverage, and I&D of the left antecubital abscess. Nasogastric tube placed secondary to gastroparesis and coffee-ground emesis, which showed some improvement. PT and OT evaluation for ongoing therapy. Management of the patient’s sugars and hypertension with the above medications and sliding scale insulin coverage.
The patient was stable for transfer with the current diagnoses of CVA, cocaine withdrawal with the current nasogastric tube in place. The patient was continued on diltiazem 3 mg via an NG tube, insulin sliding scale, and clotrimazole for the cutaneous candidiasis. The patient was later switched to glipizide, and insulin sliding scale was continued. Antibiotic coverage, which included vancomycin and gentamicin, were discontinued. The patient was continued on Ancef and rifampin. Catapres patch was later discontinued. The patient was managed on Altace 5 mg p.o. daily and clonidine 0.1 mg p.o. b.i.d. The patient’s blood pressures came under better control. The patient’s neurological status was stabilized. Sugar control was improved. The patient began tolerating clear diet and later regular diet. The patient had a PICC line placed for outpatient antibiotic coverage. The patient was to be discharged on Ancef x10 days via IV.
Discharge planning was performed for this patient. He was 11 days after initial admission. Hospital day #12, discharged to rehabilitation center for maximum rehabilitation.
FINDINGS AND PROCEDURES PERFORMED: CAT scan, MRI, MRA x2 revealing a left parietal hematoma, followed by Neurosurgery and Neurology, with no intervention other than PT and OT therapy and Dilantin therapy. The patient was seen by Infectious Disease secondary to bacteremia, infected prior IV line. He underwent transesophageal echocardiogram, which was negative. Appropriate antibiotic coverage. The patient also underwent Doppler studies of the lower extremities secondary to edema and prior DVT, which were negative. The patient was also seen by Podiatry with a diagnosis of onychomycosis. The patient had a GI consult secondary to coffee-ground emesis and coagulopathy, which would later improve. The patient also underwent an abdominal ultrasound for the same reasons, which was found just notable for fatty liver. The patient also underwent extensive ICU care and continued monitored bed. Appropriate management for diabetes and hypertension and outpatient antibiotic therapy.
DISCHARGE CONDITION: The patient was stable.
DIET: As tolerated.
ACTIVITY: Per inpatient rehabilitation center.
MEDICATIONS: Ancef x10 days, Altace 5 mg p.o. daily, clonidine 0.1 mg p.o. b.i.d., and Lipitor. We are uncertain on management of the future anticoagulation given a history of DVT but no anticoagulation obviously at this point.
FOLLOWUP: Followup is going to be with Neurology, GI p.r.n. and Medicine for continuous inpatient and outpatient care.
