DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
REASON FOR ADMISSION: Cerebrovascular accident with left hemiparesis and hemiplegia.
FINAL DIAGNOSES: Cerebrovascular accident, left hemiplegia, hydronephrosis, transitional cell carcinoma involving the bladder status post transurethral resection of the bladder tumor, hydronephrosis with gross hematuria, atrial fibrillation, hypertension, anemia, debility, dysphagia, status post PEG placement, and cardiomyopathy.
DISCHARGE INSTRUCTIONS: Skilled nursing facility.
MEDICATIONS: Aldactone 25 daily, Lexapro 10 mg via G-tube daily, Pravachol 40 daily, hydralazine, Colace 100 b.i.d., bilateral lower extremity compression stockings, PEG care, tube feedings at 60 mL per hour, Reglan 10 t.i.d., and Prevacid 30 daily.
CONDITION ON DISCHARGE: Afebrile, normotensive, heart rate well controlled. Tolerating tube feeds.
MENTAL STATUS: Arousable but lethargic.
DISCHARGE LABORATORIES: Hemoglobin of 13.6, platelet count 266,000, INR 1.24, potassium 4.2, BUN and creatinine 28 and 0.9. Glucose is 122. Unremarkable liver function tests. Lipid panel with good HDL at 74, LDL of 100. Urine test showed hematuria. Urine culture done is essentially negative, status post PEG tube placement.
RADIOLOGICAL INVESTIGATIONS PERFORMED:
1. Ultrasound of the kidneys showed echogenic kidneys, status post medical renal disease. Moderate left hydronephrosis.
2. MRI of the brain with and without shows large acute right middle cerebral infarct.
3. MRI of the head and neck shows lack of flow in the right MCA consistent with large right MCA infarct. Left dominant vertebral artery. Right internal carotid artery occlusion.
4. MRI of the neck showed mild narrowing, proximal left internal carotid artery, estimated 20 to 30%, findings consistent with complete occlusion of right internal carotid artery near its origin.
5. Moderate narrowing at the origin of vertebral arteries bilaterally.
6. Nuclear bone scan showed no evidence of metastatic disease in the bones.
HOSPITAL COURSE: The patient is a very pleasant elderly (XX)-year-old Hispanic male who came in with dense left hemiplegia. He was felt to have acute right MCA infarct. The patient also was found to be hypertensive. It was felt that the patient would need anticoagulation. The patient was initiated on anticoagulation when he started having severe hematuria. Subsequent evaluation revealed the presence of a bladder tumor. The patient continued to have significant dysphagia. The patient was found to have bladder tumor. Because of his hematuria, which actually complicates even his prior stint of anticoagulation, we had to stop on anticoagulation. The patient was recommended to have a PEG tube placement. Subsequently, was seen and evaluated with Cardiology and cleared for surgery at high risk and underwent transurethral resection of bladder. The patient’s postoperative course was complicated with his debility, decreased p.o. intake. He was started on tube feeds. He continued to tolerate tube feeds. He was also seen by Oncology and initiated on radiation therapy. He received radiation therapy as an inpatient at the recommendation of Oncology. The patient was also seen in consultation by Dr. Jane Doe for neurointerventional radiology and no immediate intervention recommended. It was felt that there was no reason for right ICA occlusion. The patient’s MRI of the neck did not show any significant vertebrobasilar stenosis. The patient is being discharged to a skilled nursing facility. His prognosis continues to remain poor. He is not being initiated on anticoagulation. His risk for aspiration, pressure sores, decubiti, recurrent pneumonia, vent-dependent respiratory failure and other morbidities are high, especially given the fact that he is bed bound. We explained details to the patient. The patient is discharged to SNF today. The patient will be followed up as an outpatient by the relevant physicians involved in his care.
