DEPARTMENT OF INTERNAL MEDICINE

DISCHARGE SUMMARY
Registration #: 123037
Case #: 126579
Room #: 506-D
Name: Debayan Chatterjee
Age/Sex: 21y
Working Diagnosis: CVA Infarct
Final Diagnosis: Acute Cerebral Infarct, Left Corona Radiata and Posterior Limb of Internal capsule probably SVD,
NIHSS 5, HCVD SR FC I
Date of Admission: January 12, 2023
Doctors-in-Charge: Dr. Prabhua

Address:

.
Department: Internal Medicine

CLINICAL HISTORY
January 28, 2023 Informant: Patient
Reliability: 85%

GENERAL DATA:
.

CHIEF COMPLAINT: weakness of right upper and right lower extremities for 3days

HISTORY OF PRESENT ILLNESS:

History of present illness started Three days prior to admission, the patient experienced sudden
weakness of right upper and right lower extremities accompanied by diaphoresis, dizziness non-rotatory and
headache described as pulsatile, nonradiating located at left occipito-parietal region with a pain scale of 5/10,
relieved by rest. There were no other signs and symptoms such as loss of consciousness, slurring of speech, fever,
chills, vomiting. No medications taken. No consultation done.

Two hours prior to admission, still with the above symptoms, now accompanied with slurring of speech. This
prompted consult to our institution and was subsequently admitted.

PAST MEDICAL HISTORY:

Had mumps, measles, and chickenpox during childhood
Not known hypertensive
 Not known diabetic
(-) Bronchial Asthma
(-) Allergies to food and drugs
Accident:1976- was hit by a steel in his chest,
REVIEW OF SYSTEMS:
Constitutional symptoms: (-) body weakness (-) fever (-) weight loss
Skin: (-) itchiness, (-) excessive sweating, (-) cyanosis, (-) pallor, (-) jaundice
Head: (-) dizziness (-) headache, (-) vertigo,
Eyes: (+) blurring of vision(Left), (-) excessive lacrimation (-) photophobia
Ears: (-) earache, (-) deafness, (+) tinnitus, (-) ear discharge
Mouth & Throat: (-) sore throat, (-) toothache, (-) gum bleeding, (-) disturbance in taste
Neck: (-) mass, (-) neck vein engorgement
Respiratory: (-) hemoptysis, (-) difficulty of breathing, (-) orthopnea
Cardiovascular: (-) palpitations, (-) syncope
Gastrointestinal: (-) loss of appetite, (-) abdominal pain, (-) nausea, (-) vomiting, (-) dysphagia, (-) diarrhea, (-)
constipation
Genitourinary: (+) difficulty of urination, (-) urinary frequency, (-) urgency, (-) hematuria. (-) nocturia
Extremities: (-) edema, (-) swelling of joints, (-) limitation of movement, (-)lesions
Nervous: (-) headache, (-) vertigo, (-) syncope, (-) numbness, (-) loss of memory, (-) loss of consciousness
Hematologic: (-) pallor, (-) easy bruising
Endocrine: (-) intolerance to heat & cold, (-) polydipsia, (-) polyuria

PHYSICAL EXAMINATION
General Survey: Patient is conscious, coherent, not in cardiorespiratory distress. Looks appropriate for his age and
he is oriented to time place and person with the following vital signs:
BP: 150/100 mmHg CR: 73bpm RR: 19cpm Temperature: 36.7°C 02 Sat: 98%

Skin: Brown in color, has normal mobility, dry. Nail beds are pink, nail plates are smooth, no lesion; nail folds are
normal looking.

Head: Hair is black to gray, thick, evenly distributed, normocephalic, symmetrical, no mass, no tenderness,
temporal arteries are not visible but palpable, with strong equal pulsations.

Eyes: Eyebrows are black, evenly distributed, no erythema and no lesions noted; palpebral fissures symmetrical;
eyelashes are thin with outward direction of growth, no matting, no exophthalmos or enophthalmos on both eyes.
Pink palpebral conjunctivae, yellowish white sclerae at the nasal and temporal side, no clouding of the cornea,
irises are dark brown with regular contour, pupils measure 2-3 mm and equally reactive to light.

Ears: Symmetrical, Tympanic membranes were not seen due to complete blockage of thick flaky material.

Nose: Symmetrical, with patent vestibules, and mucosa is pink, septum at midline and intact, no congested
turbinates, no nasal discharge.

Mouth and Oral Cavity: Lips are pink and moist; buccal mucosa and gums are pinkish and smooth. Tongue is
slightly deviated to the right upon protrusion. Uvula is at midline. Tonsils not enlarged.

Neck: Symmetrical, soft, supple neck, no deformities, no palpable lymph nodes. Thyroid gland is not palpable. No
neck vein engorgement. No carotid bruit noted.

Lungs/Chest: Skin is brown, no visible mass, no dilated superficial blood vessels, symmetrical chest expansion, no
supraclavicular and intercostal retractions noted.
Heart: Adynamic precordium, no precordial bulging, apex beat is at the 5 th intercostal space left midclavicular line,
normal rate & regular rhythm. S2 is louder than S1.

Abdomen: Symmetrical, brown, no lesions, no scars. Flat abdomen with normoactive bowel sounds. No bulging
flanks. No tenderness upon superficial and deep palpation. Superficial blood vessels are not visible and not
palpable. No abnormal pulsations, no visible peristalsis

Extremities: No gross deformities, no edema with full equal pulses, no cyanosis.

NEUROLOGIC EXAMINATION
Cerebrum: Patient is conscious, awake, oriented to time place and person, can talk spontaneously and follow
verbal commands. GCS score of 15 (E4V5M6)
Cerebellum: No nystagmus, no intention tremors, (-) Romberg’s sign, (-) tactile agnosia, can follow simple
instructions and answer questions, can do finger-to-nose test

Cranial nerves:
CN I: can smell coffee
CN II: ophthalmoscopic findings: (+) ROR and (+) direct and indirect light reflex, AV ratio 2:3
CN III, IV, & VI: Intact EOMs, no ptosis
CN V: (+) corneal reflex, bilateral; can clench teeth equally on both sides, can distinguish light touch, with pain
sensation, can open and close mouth without difficulty
CN VII: No facial asymmetry closes eyes tightly, can raise eyebrow, can frown
CN VIII: (-) lateralization in Weber’s Test; AC>BC in Rinne’s Test
CN IX and X: (+) swallowing; (+) gag reflex; uvula at midline
CN XI: can shrug both shoulders but with weakness on the right
CN XII: Tongue deviated to the right upon protrusion

COURSE IN THE WARD

Upon admission to Internal Medicine Station 5B, patient has a GCS of 15 (E4V5M6), not in cardiorespiratory
distress, with the following vital signs: BP – 150/100, HR – 73, RR – 19, Temp – 36.7, O2 sat – 98%. Laboratory tests
done were CBC , Serum Na, K, Creatinine, SGPT, CBG, FBS, Lipid profile, 12lead ECG, Chest X-Ray, Urinalysis
which revealed normal WBC (8.53) with predominance of neutrophils (.93mmol/L) and monocytes (0.070mmol/L),
normal serum Sodium (Na: 138 mmol/L), normal serum K (3.90 mmol/L), high hemoglobin (165g/L), normal
hematocrit (0.484L/L) normal MCV (86.7 fl, normal MCH (29.6pg), Normal MCHC (341 g/L), normal RDW-CV(13.1%),
normal RDW-SD (41fl), normal platelet count (196 x10^9/L), normal MPV (8.8 fl) and normal PDW (9.0 fl).
Urinalysisrevealed yellow, hazy, no blood and bilirubin, Urobilinogen of +1, no trace of ketone, protein, nitrite,
leukocytes and glucose with a pH of 8.0, specific gravity of 1.010, with an occasional epithelial cells, urates and
bacteria. Non-contrast cranial MRI showed an acute ischemic infarction, Left corona radiate and posterior limb of Left
internal capsule, chonic small vessel ischemic changes, nonspecific blooming artifact with shine-through is seen in
the right frontal area. CBG revealed 89mg/dl. PNSS 1L at 60cc/hour now was started. On low salt low fat diet. Vital
signs were monitored every hour and I. Intake and Output were monitored every shift. He’s on ASA 80mg/tab OD
after lunch, Atorvastatin 40mg/tab, 1tab ODHS, Citicholine 1g/tab BID, Omeprazole 40mg/tab OD, Lactulose 30cc
ODHS hold for BM>2x/day, maintained MAP of 110-130mmHg, elevated head of the bed 30degrees, was referred to
Neuro for evaluation.
On the 2nd hospital day, lactulose was increased to 20cc BID and was hold for when bowel movement is
greater than twice a day. IV fluid was decreased to 60cc per hour and progression of neurologic deficit was watched
out for. Bactidol gargle was started 15ml TID for 60 seconds and was referred accordingly. Na, K, Ca++ and SGPT
were followed up
On the 3rd hospital day to consume iVF then shift to heplock. He can sit and drag feet and he was referred
to rehab.
On the 4th hospital day, rehabilitation was facilitated and the patient was given Dulcolax suppository for
bowel movement.

LABORATORY EXAMINATIONS

12/9/15
TEST RESULT UNIT REF. RANGE
Glucose (FBS) 5.58 mmol/L 4.11-5.589 mmol/L
LIPID PROFILE
Total cholesterol 5.62 mmol/L 0.00-5.20 mmol/L
Triglyceride 1.48 mmol/L 0.0-2.26 mmol/L
HDL 1.33 mmol/L Male: >1.45 mmol/L
Female: >1.68 mmol/L
LDL 3.62 mmol/L 0.00-2.59 mmol/L
VLDL 0.67 mmol/L 0.00-0.34 mmol/L

PHYSICAL EXAMINATION UPON DISCHARGE

General Survey: Patient is conscious, coherent, not in cardiorespiratory distress. Looks appropriate for his age and
he is oriented to time place and person with the following vital signs:
BP:120/90 CR: 75 RR: 19 Temperature: 37.2 02 Sat: 96%

Skin: Brown in color, has normal mobility, dry. Nail beds are pink, nail plates are smooth, no lesion; nail folds are
normal looking.

Head: Hair is black to gray, thick, evenly distributed, normocephalic, symmetrical, no mass, no tenderness,
temporal arteries are not visible but palpable, with strong equal pulsations.

Eyes: Eyebrows are black, evenly distributed, no erythema and no lesions noted; palpebral fissures symmetrical;
eyelashes are thin with outward direction of growth, no matting, no exophthalmos or enophthalmos on both eyes.
Pink palpebral conjunctivae, yellowish white sclerae at the nasal and temporal side, no clouding of the cornea,
irises are dark brown with regular contour, pupils measure 2-3 mm and equally reactive to light.

Ears: Symmetrical, Tympanic membranes were not seen due to complete blockage of thick flaky material.
Nose: Symmetrical, with patent vestibules, and mucosa is pink, septum at midline and intact, no congested
turbinates, no nasal discharge.

Mouth and Oral Cavity: Lips are pink and moist; buccal mucosa and gums are pinkish and smooth. Tongue is
slightly deviated to the right upon protrusion. Uvula is at midline. Tonsils not enlarged.

Neck: Symmetrical, soft, supple neck, no deformities, no palpable lymph nodes. Thyroid gland is not palpable. No
neck vein engorgement. No carotid bruit noted.

Lungs/Chest: Skin is brown, no visible mass, no dilated superficial blood vessels, symmetrical chest expansion, no
supraclavicular and intercostal retractions noted.

Heart: Adynamic precordium, no precordial bulging, apex beat is at the 5 th intercostal space left midclavicular line,
normal rate & regular rhythm. S2 is louder than S1.

Abdomen: Symmetrical, brown, no lesions, no scars. Flat abdomen with normoactive bowel sounds. No bulging
flanks. No tenderness upon superficial and deep palpation. Superficial blood vessels are not visible and not
palpable. No abnormal pulsations, no visible peristalsis

Extremities: No gross deformities, no edema with full equal pulses, no cyanosis.

NEUROLOGIC EXAMINATION
Cerebrum: Patient is conscious, awake, oriented to time place and person, can talk spontaneously and follow
verbal commands. GCS score of 15 (E4V5M6)
Cerebellum: No nystagmus, no intention tremors, (-) Romberg’s sign, (-) tactile agnosia, can follow simple
instructions and answer questions, can do finger-to-nose test

Cranial nerves:
CN I: can smell coffee
CN II: ophthalmoscopic findings: (+) ROR and (+) direct and indirect light reflex, AV ratio 2:3
CN III, IV, & VI: Intact EOMs, no ptosis
CN V: (+) corneal reflex, bilateral; can clench teeth equally on both sides, can distinguish light touch, with pain
sensation, can open and close mouth without difficulty
CN VII: No facial asymmetry closes eyes tightly, can raise eyebrow, can frown
CN VIII: (-) lateralization in Weber’s Test; AC>BC in Rinne’s Test
CN IX and X: (+) swallowing; (+) gag reflex; uvula at midline
CN XI: can shrug both shoulders but with weakness on the right
CN XII: Tongue deviated to the right upon protrusion