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Clinical_Documents_on_Syndromes_Disease

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HOSPITAL COURSE PER PROBLEM LIST:

1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT

OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.

2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.

3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.

4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.

CONDITION ON DISCHARGE:

Stable.

ACTIVITY:

As tolerated.

DIET:

Low-fat, low-salt, cardiac diet.

DISCHARGE INSTRUCTIONS:

1. Take medications regularly.

2. PT

OT

speech therapist to evaluate and treat at Siskin Rehab Hospital.

3. Continue Cipro for an additional two days for his UTI.

DISCHARGE MEDICATIONS:

1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.

2. Aggrenox, one tablet p.o. b.i.d.

3. Docusate sodium 100 mg, one cap p.o. b.i.d.

4. Zocor 20 mg, one tablet p.o. at bedtime.

5. Prevacid 30 mg p.o. once a day.

FOLLOW UP:

1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.

2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.

CAUSE OF DEATH:

1. Acute respiratory failure.

2. Chronic obstructive pulmonary disease exacerbation.

SECONDARY DIAGNOSES:

1. Acute respiratory failure, probably worsened by aspiration.

2. Acute on chronic renal failure.

3. Non-Q wave myocardial infarction.

4. Bilateral lung masses.

5. Occlusive carotid disease.

6. Hypertension.

7. Peripheral vascular disease.

HOSPITAL COURSE:

This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months. The patient was admitted again on 12/15/08, after he had been discharged the previous day. Came in with acute on chronic respiratory failure, with CO2 of 57. The patient was in rapid atrial fibrillation. RVR with a rapid ventricular response of 160 beats per minute. The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation. The patient's heart rate was controlled with IV Cardizem. Troponin was consistent with non-Q wave MI. The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease. Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology. There was also prosthetic aortic valve. The patient was admitted to Intensive Care Unit and was intubated. Pulmonary was managed by Critical Care, Dr. X.

The patient was successfully extubated. Was tapered from IV steroids and put on p.o. steroids. The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3. There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status. Wife decided catheterization should be canceled and the patient managed conservatively. The patient was transferred to the telemetry floor. While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days. The patient had nausea and vomiting. Was unable to tolerate p.o. Was put on cautious hydration. The patient went into acute respiratory distress. Intubation showed the patient had aspirated. He was in acute respiratory failure with bronchospasms and exacerbation of COPD. X-ray of chest did not show any infiltrate, but showed dilatation of the stomach. The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X. The patient was put on the vent. Overnight, the patient's condition did not improve. Continued to be severely hypoxic.

The patient expired on the morning of 12/24/08 from acute respiratory failure.

DIAGNOSIS:

Cognitive linguistic impairment secondary to stroke.

NUMBER OF SESSIONS COMPLETED:

5,HOSPITAL COURSE:

The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.

She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge.

DISCHARGE DIAGNOSES:

1. Acute respiratory failure, resolved.

2. Severe bronchitis leading to acute respiratory failure, improving.

3. Acute on chronic renal failure, improved.