Community Health Hospital Patient ID: 12345
Patient Name: Levin, Henry L.
Discharge Summary
Date of Discharge: 03/26/2009
Description: Acute cerebrovascular accident/left basal ganglia and deep white matter of the left
parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.
DISCHARGE DIAGNOSES:
1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal
lobe.
2. Hypertension.
3. Urinary tract infection.
4. Hypercholesterolemia.
PROCEDURES:
1. On 3/2612009, portable chest, single view. Impression: atherosclerotic change in the aortic
knob.
2. On 3/2612009, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta,
maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to
positioning of the patient.
3. On March 27, 2009, swallowing study: Normal swallowing study with minimal penetration with
thin liquids.
4. On March 26, 2009, head CT without contrast: 1) Air-fluid level in the right maxillary sinus
suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the
left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right
maxillary sinus and ethmoid sinuses. 4. IV contrast CT scan of the head is unremarkable.
5. On 3/26/2009, MRI/MRA of the neck and brain, with and without contrast: 1) Changes
consistent with an infarct involving the right basal ganglia and deep white matter of the left
parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery
that may be a congenital abnormality. Clinical correlation is necessary.
6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular
systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric
left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.
7. On March 27, 2009, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the
right; 2) No evidence of carotid stenosis on the left.
HISTORY AND PHYSICAL: This is a 56-year-old white male with a history of hypertension for
15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of
right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand
numbness on the dorsal side, left face numbness and slurred speech. The patient was brought
by EMS to emergency room. The patient was normal before he went to bed the prior night. He
was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He
could not have a CT with contrast because the machine was broken. He went ahead and had
the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and
deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left
middle cerebral artery.
The patient was admitted to the MICU.
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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. 8. 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. Wiseman 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.
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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.
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