SUBJECTIVE: The patient was very emotional today when we saw him. He stated that he was miserable, and he was very upset. Apparently, there was no specific reason, although he was frustrated with hiccups. Apparently, this was the first day his wife was not with him for most of the time and perhaps this contributed. Certainly, once the wife was in the room, he appeared to calm down quite substantially.
OBJECTIVE: On his examination, his blood pressure was 162/74, pulse was 72, respirations 22, and temperature 99.2 degrees. His lungs were clear to auscultation. Cardiac examination showed regular rate and rhythm. Normal S1 and S2. Abdomen was soft and nontender. Good bowel sounds noted. His extremity examination was unremarkable. He was very emotionally labile as indicated. He had fair movement in the right upper extremity with elbow flexion in a synergy pattern. He did have weakness, however, in the hand and intrinsic muscles. In the right lower extremity, he is demonstrating good strength. At the time when I saw him, he was not experiencing any hiccup.
LABORATORY DATA: On review of his laboratory data, everything appeared stable; although, this BUN and creatinine were still slightly elevated at 34 and 1.4. We will need to continue to monitor this.
ASSESSMENT AND PLAN:
1. Blood pressure: His blood pressures have been stable with Cardizem, lisinopril, and Norvasc. We will repeat a BMP on Thursday, and if that continues to trend upward, we will arrange for internal medicine consultation as well.
2. Emotional lability: This is certainly related to Decadron. We explained to his wife that short-term use of a serotonergic agent maybe beneficial; however, at this point, he was reluctant to be on any other medication. We did meet with him with the rehabilitation psychologist and the plan would be to utilize psychology supportive counseling for now and monitor whether something such as Zoloft would be beneficial.
3. Deep venous thrombosis prophylaxis: The patient’s Doppler did show a superficial thrombus in the saphenous, otherwise was stable. Will progress with activities as ad lib. Continue on the Fragmin.
4. Diabetes: His blood sugars were very elevated last evening; however, it was only 134 for fasting and 234 at 10:30. We will not adjust his insulin right now, but continue to monitor at this point whether further adjustments are necessary.
5. Bladder: It appears that he is voiding; however, did not discern any postvoid residuals. We wrote once again for nursing to obtain these.
6. Sleep: His sleep seems somewhat restless, and therefore, we scheduled trazodone with a repeat ordered as well.
7. Elevated alkaline phosphatase: The rest of his liver enzymes were normal, but we will continue to monitor this.
8. Potential coronary artery disease with the diabetes and hypertension: We will check to see if we can have a copy of the EKG faxed from the previous facility.
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SUBJECTIVE: The patient is much more calmer. He reports no specific complaints. He was observed ambulating with physical therapy and did fairly well. He did have his foot Ace wrapped. He was noted to have a fairly pronounced genu recurvatum. He also held his leg externally rotated.
OBJECTIVE: His blood pressure was 124/64, pulse 86, respirations 18, and temperature 98.6 degrees. Lungs were clear to auscultation. Cardiac examination with regular rate and rhythm. Normal S1 and S2. Abdomen was soft and nontender with good bowel sounds. Extremity examination with no edema noted. He had atrophy in his intrinsics on the right hand. On neurologic examination, he was demonstrating good elbow flexion but still very little finger movement or grip on the right hand. He was beginning to demonstrate volitional ankle dorsiflexion and plantarflexion on the right and appeared to be doing much better with that. Also, he had less apraxia of speech.
ASSESSMENT AND PLAN:
1. Cerebrovascular accident: We discussed the case in team conference and actually the patient has made significant progress since last week. He did not seem to have the pronounced fatigue that he had had initially and appears to be acclimating to the radiation treatment. He has progressed in all therapy areas and at this point may be able to get to the point where he could be discharged home with his wife. We will discuss this further with her.
2. Diabetes: His blood sugars have been in fairly good control on the current regimen. He is on low dose of insulin. We will consider taking him off the insulin and using oral hypoglycemic medications. We will check with him further about this.
3. Hypertension, stable on current regimen.
4. Gait abnormality: We did write for a custom-molded AFO to see if this will work for him. We also discussed with Dr. John Doe about Botox injections for the posterior tibialis muscle depending on how he does with therapy.
5. Azotemia: His BUN and creatinine are much improved. Now, his BUN is only slightly elevated and his creatinine has decreased to a normal range.
6. Deep venous thrombosis prophylaxis: It was reported in the therapy that he is walking greater than 120 feet x2, and therefore, we will be able to discontinue his subcutaneous heparin.
