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2005-12-03 11:22 p.m. Ilkcan CokGor HISTORY OF PRESENT ILLNESS:The patient is a 48 year old right handed female who was admitted to the hospital because of a severe headache and somewhat altered mental status. The patient was fouund to be very hrppertensive. She was complaining of some headaches for a while and when she came, the blood pressure was 240/140, and the CT of the brain showed a left temporal lobe hemorrhage with a punctuate hemorrhage on the right cerebellum. The neurosurgeon was consulted and no surgery needed, so far she is still not obtunded and she is neurologically doing well and that is why I was consulted and the patient denies any past medical history of such a thing.She was very healthy up untilnow. She did not know that she suffered from hypertension and it is brand new and it was called as hypertensive crisis. The patient is now on labetalol and Nipride drip. She was not taking any medications. PAST MEDICAL HISTORY: MEDICATIONS: Aspirin ALLERGIES: None SOCIAL HISTORY: She is married. She denies any tobacco and alcohol abuse or drug abuse. REVIEW OF SYSTEMS: Right now, she states that she is not having any vertigo, dizziness, headaches, etc. The neurological exam shows that she is awake, alert, oriented 4 times. Her cranial nerves II through XII are intact. No facial droop. The motor exam shows right pronator drift and 4+/5 right arm weakness. The leg is better compared to the left side. The sensory exam is intact to light touch and temperature. Deep tendon reflexes are 2 everywhere. Toes are downgowing. Coordination is intact and gait, I did not check it. IMPRESSION:The patient is suffering from very mild effects of the intercranial hemorrhage. So far, she is actually doing well and is sleepy. We have to observe her neuro exam very carefully in the ICU and we have to treat the blood pressure but not drop it too much. I agree with Nipride and lebetolol, we are going to continue with it, hold off old anticoagulation. She may need Mannitol if the neuro exam z | ||
