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beautiful pink lava erupting in this dreamstate horizon
2005-11-29 4:52 p.m.

EMERGENCY DEPARTMENT COURSE: The Patient is kept n.p.o. in the event she has an acute neurosugical condition of bleed. The patient is given Compazine for nausea and Dilaudid for pain. She is ordered to have normal saline at 100cc an hour and she is kept n.p.o. and she is given analgesics and antiemetics to see it will relieve her pain may times to see her blood pressure response well to treatment of her pain. Figures comes down somewhat one measurement is 172/112. The patient's response is not adequate however and so labetalol 20 mg IV slow push is orderedin two boluses of 20 mg in effort to reduce her blood pressure by 25% of her mean arterial pressure. The patient undergoes workup, which includes head CT, chest x-ray, an EKG and labs.Urine is ordered as well. She has head CT, which reveals evidence of intercranial hemorrhage x2, this one on the left temporal region and one on the right posterior occipital region, the one on the left shows no significant midline shift. It is described as a parenchymal hemorrhage in the left temporal lobe with mild defacement of temporal horn. There is punctate hemorrhage in the right cerebellum. Systems are normal there is no herniation. There are multiple old lacunar changes, vasculopathy, emboli underlying lesion not excluded. Given the history of extreme and poorly controlled hypertension, I think these are likely to be hypertensive bleeds as the patient's CT is seen and evaluated by me and the neuroradiologist and I immediately contacted the neurosurgeon Dr. Blumenfeld who is advised of these findings. He reports that he will follow the patient. The patient will be admitted to the hospitalist service for further management of her extremely elevated blood pressure. Her labs are really fairly unremarkable, sodium is 133, potassium 3.4, chloride 102, bicarb 24, glucose 98, BUM 12 and creatinine 0.7. The patient has an alkaline phosphatase of 134, AST of 18, ALT of 19. The patient's UA was ordered but pending at the time of admission certainly it will be important to look for signs of hematuria and/or infection.

IMPRESSION:
1. Cranial bleeds x2 likely hypertension related hemorrhages
2. Hypertension untreated and out of control. Hypertensive urgency.